Form De 945 - Annual Income Report For Disability Insurance Elective Coverage - Employment Development Department, State Of California

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DE 945 ANNUAL INCOME REPORT FOR
DISABILITY INSURANCE ELECTIVE COVERAGE
THIS IS NOT A BILL
YEAR
YEAR ENDED
DUE
DIEC Account Number
Social Security Number
DO NOT ALTER THIS AREA
Mo.
Day
Yr.
EFFECTIVE
=
=
=
DATE
The net profit or loss reported for the calendar year shown above will be used to determine your quarterly
premiums for the following year. Those premiums will determine your benefits for future years.
1. Enter the net profit or loss from line 3 of your Internal Revenue Service (IRS) Schedule SE
$
in this box. (Please attach a copy of your Schedule SE to this form.)
Net Profit <Loss> from IRS
OR
Schedule SE, C, F, or K-1
2. If you did not file an IRS Schedule SE, enter the net profit or loss
from your IRS Schedule C, F, or K-1.
(Please attach a copy of the appropriate schedule to this form.)
Note: The name and the last four digits of your social security number on your schedules(s) must agree with
those preprinted on this form. If the IRS has granted you a filing extension, please DO NOT submit this
form until you file your tax return.
BE SURE TO SIGN THIS DECLARATION: I DECLARE that the information herein is true and correct to the best of
my knowledge and belief.
Signature _______________________________________
Title ________________________________
Telephone (
) ___________
Date ____/____/____
THIS IS NOT A BILL
PLEASE DO NOT SEND PAYMENTS WITH THIS FORM
P.O. Box 826880 / MIC 5 / Sacramento, CA 94280-0001
DE 945 Rev. 5 (2-11) (INTERNET)
Page 1 of 2
CU

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