Form De 459 Sole Shareholder/corporate Officer Exclusion Statement

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SOLE SHAREHOLDER/CORPORATE OFFICER EXCLUSION STATEMENT
(Section 637.1, California Unemployment Insurance Code)
Please print or type. Prepare an original and one copy. Mail or Fax immediately upon completion to the address shown on
the back of this form. Do not wait to file with the Quarterly Wage and Withholding Report (DE 6) as it is effective in
the calendar quarter filed. Retain the copy with your payroll records.
Employer Account No. _________________________________________
Federal Employer Identification No. (FEIN) _______________________________________________________________
Corporation Name __________________________________________________________________________________
Doing Business As __________________________________________________________________________________
Corporation Mailing Address __________________________________________________________________________
Street
City
State
ZIP Code
Contact Person’s Telephone (
) _______________________
Fax Number (
) ___________________________
Sole Shareholder Name ________________________________________
SSA # ______________________________
Sole Shareholder’s Spouse Name (
) _______________________________
SSA # __________________________
Eligibility Requirements
In a private corporation, any person who is a corporate officer and sole shareholder, or the only shareholder other than his
or her spouse, may file a statement electing to be excluded only from state disability insurance coverage for contributions
and benefits*.
I hereby declare that I am a corporate officer of the above-named corporation organized for profit, and I am
CHECK
the sole shareholder or
ONLY ONE
the only shareholder other than my spouse.
Election Statement
I hereby elect to be excluded from any rights to state disability insurance benefits based on wages paid to me by this
corporation.
Spouse (if electing)
IMPORTANT - PLEASE NOTE CAREFULLY
The corporation must report your wages and pay contributions for unemployment insurance unless your corporation is not
subject to the Federal Unemployment Tax Act (FUTA). Only certain types of nonprofit and agricultural corporations are not
subject to FUTA.
I understand this statement is effective in the calendar quarter filed and remains in effect for not less than two complete
calendar years and in all subsequent calendar quarters until withdrawn. Any changes in the ownership of the stock or
status of the corporate officer may terminate this exemption. I also understand that this exclusion applies only to State
Disability Insurance taxes administered by the State of California and has no effect on the administration of Federal
Unemployment Insurance taxes.
Sole Shareholder’s Signature _______________________________________ Date _____________________________
Sole Shareholder’s Spouse Signature ____________________________________ Date__________________________
FOR DEPARTMENT USE ONLY
EFF. DATE __________ LTR. SENT _____________
EXAMINER __________ DATE _________________
SEE REPORTING INSTRUCTIONS ON REVERSE SIDE
* Includes Paid Family Leave (PFL) contributions beginning January 1, 2004, and PFL benefits beginning July 1, 2004.
DE 459 Rev. 12 (2-05) (INTERNET)
Page 1 of 2
CU

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