Form De 938p - Claim For Adjustment Or Refund Of Personal Income Tax
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1Auditor’s Name _______________________________
Phone Number ________________________________
Assessment # _________________________________
Case # _______________________________________
CLAIM FOR ADJUSTMENT OR REFUND OF PERSONAL INCOME TAX
Account Number
Social Security Number (SSN)
(2) Worker Identification
(1) Business/Principal Identification
Name (Print)
Name (Print)
Address
DBA
Address
City, State, ZIP Code
City, State, ZIP Code
This Portion to Be Completed by the Worker
(5) Name and SSN as shown on the State of California income
(3) Total Earnings Subject to Personal Income Tax Withholding
tax return(s) (Form 540 or Form 540NR) for the year(s) listed
in Item (3).
Calendar Year
Your Name _________________________________________
Reported on Form W-2
Your SSN __________ – ________ – ________________
Additional Earnings
Spouse’s Name _____________________________________
1st Quarter
Spouse’s SSN __________ – ________ – _____________
2nd Quarter
Current address, if different from Item (2) above.
3rd Quarter
____________________________________________________
4th Quarter
____________________________________________________
Total Additional Earnings
(6) I reported the following earnings from this entity on my
Total Earnings
California income tax return(s): (NOTE: If your total income
received for any of the indicated years was insufficient to
require a California income tax return, write N/R in the box for
(4) Computation of Tax Due (Refer to Instructions)
that year.)
Calendar Year
Year
1st Quarter
Earnings
2nd Quarter
If you paid taxes prior to the April 15 deadline, please complete
the following section.
3rd Quarter
I paid the following estimate(s) (Form 540ES):
4th Quarter
Year
Totals
04/15
06/15
(8) Business/Principal Certification
09/15
I certify that to the best of my knowledge and belief, the signature in
01/15
Item (7) is valid and legal.
I paid the following amount(s) with my Form 540 or Form 540NR:
The tax in Item (4) was based upon a valid Employee’s Withholding
Allowance Certificate (copy attached) that was in my possession at the
Year
time of the payment of the earnings shown in Item (3).
Amount
A completed worksheet is attached.
Date Paid
The tax in Item (4) was calculated based upon the worker being single
with no deductions. A completed worksheet is attached.
(7) Under penalty of perjury, I certify that the information shown
in Items (5) and (6) above is true and correct.
Signature of Business/Principal Representative
Date
Signature of Worker
Date
Return To:
Date Stamp
DE 938P Rev. 12 (5-13) (INTERNET)
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