Fillable Form De 459 - Sole Shareholder/corporate Officer Exclusion Statement printable pdf download

SOLE SHAREHOLDER/CORPORATE OFFICER EXCLUSION STATEMENT

(Section 637.1 of the California Unemployment Insurance Code [CUIC])

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 (SDI) coverage for

contributions and benefits, which includes Paid Family Leave (PFL).

I hereby declare that I am a corporate officer of the above-named private corporation, and I am

CHECK

the sole shareholder, or

ONLY ONE

the only shareholder other than my spouse.

Please print or type. Prepare an original and retain a copy with your payroll records. Mail or fax immediately upon completion to

the address or fax number shown on the Reporting Instructions. Your exclusion is effective in the calendar quarter filed.

Employer Account Number _____________________________________

Federal Employer Identification Number (FEIN) __________________________________________________________

Secretary of State Corporate Entity Number _____________________________________________________________

Corporation Name _________________________________________________________________________________

Doing Business As _________________________________________________________________________________

Corporation Mailing Address _________________________________________________________________________

Street

City

State

ZIP Code

Contact Person’s Phone Number (

)

Fax Number (

)

Sole Shareholder’s Name __________________________________ SSN _______________________________________________________

Sole Shareholder’s Spouse’s Name _____________________________ SSN _________________________________

Election Statement

I hereby elect to be excluded from any rights to SDI benefits based on wages paid to me by this corporation.

Spouse (if electing to be excluded).

IMPORTANT - PLEASE NOTE CAREFULLY

The corporation must report your wages and pay contributions for Unemployment Insurance (UI) and Employment

Training Tax (ETT) unless your corporation is not subject to the Federal Unemployment Tax Act (FUTA). (Refer to

Section 637 of the CUIC.) Only certain types of nonprofit and agricultural corporations are not subject to FUTA.

I understand that this statement is effective in the calendar quarter filed and is effective during the remainder of the

calendar year in which the statement is filed and for not less than the two succeeding 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 SDI taxes administered by the State of

California and has no effect on the administration of federal UI taxes.

Sole Shareholder’s Signature ______________________________________ Date ____________________________

Sole Shareholder’s Spouse’s Signature _________________________________ Date _________________________

FOR DEPARTMENT USE ONLY

EFF. DATE __________ LTR. SENT _____________

EXAMINER __________ DATE __________________

SEE THE FOLLOWING REPORTING INSTRUCTIONS

DE 459 Rev. 18 (6-13) (INTERNET)

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Form De 459 - Sole Shareholder/corporate Officer Exclusion Statement

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