Form De 945 - Annual Income Report For Disability Insurance Elective Coverage
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2DE 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 new profit from line 3 of your IRS Schedule SE in this box.
$
(Please attach a copy of your Schedule SE to this form.)
Net Profit <Loss> from IRS
Schedule SE, C, F, or K-1
OR
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 social security number on your schedule(s) must agree with those preprinted on this
form. If you have been granted a filing extension by the IRS, 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
Phone (
)
Date
/
/
THIS IS NOT A BILL
PLEASE DO NOT SEND PAYMENTS WITH THIS FORM.
DE 945 Rev. 3 (12-05) (INTERNET) P.O. Box 826880 / MIC 5 / Sacramento, CA 94280-0001
CU-PA218
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Parent category: Financial