Form 540nr - California Nonresident Or Part-Year Resident Income Tax Return - Short Form - 2012 Page 3

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Your name: ______________________________________Your SSN or ITIN: ______________________________
121 AMOUNT YOU OWE. Add line 104 and line 120 (see page 10) . Do Not Send Cash.
.
,
,
00
Mail to: FRANCHISE TAX BOARD, PO BOX 942867, SACRAMENTO CA 94267-0001 . . . . . . . . . . . . . . .
121
Pay Online – Go to ftb.ca.gov for more information .
125 REFUND OR NO AMOUNT DUE. Subtract line 120 from line 103 .
.
,
,
00
Mail to: FRANCHISE TAX BOARD, PO BOX 942840, SACRAMENTO CA 94240-0001 . . . . . . . . . . . . . . .
125
Fill in the information to authorize direct deposit of your refund into one or two accounts . Do not attach a voided check or a deposit slip (see page 10) .
Have you verified the routing and account numbers? Use whole dollars only.
All or the following amount of my refund (line 125) is authorized for direct deposit into the account shown below:
Checking
.
,
,
00
Savings
Routing number
Type
Account number
126 Direct deposit amount
The remaining amount of my refund (line 125) is authorized for direct deposit into the account shown below:
Checking
.
00
,
,
Savings
Routing number
Type
Account number
127 Direct deposit amount
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my
knowledge and belief, it is true, correct, and complete.
Sign
Your signature
Spouse’s/RDP’s signature (if filing jointly, both must sign)
Daytime phone number (optional)
(
)
Here
X
X
Date
t is unlawful to
I
Your email address (optional) . Enter only one email address .
forge a
spouse’s/RDP’s
signature .
Paid preparer’s signature (declaration of preparer is based on all information of which preparer has any knowledge)
PTIN
Joint tax return?
(see page 11)
Firm’s name (or yours if self-employed)
Firm’s address
FEIN
 
Do you want to allow another person to discuss this tax return with us? (see page 11) . . . . . . .
Yes
No
(
)
__________________________________________________________________
__________________________________
Print Third Party Designee’s Name
Telephone Number
Short Form 540NR C1 2012 Side 3
3143123

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