Form De 938p - Claim For Adjustment Or Refund Of Personal Income Tax
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1AUDITOR’S NAME _________________________
TELEPHONE NO. __________________________
ASSESSMENT # ___________________________
CASE # __________________________________
CLAIM FOR ADJUSTMENT OR REFUND OF PERSONAL INCOME TAX
(INSTRUCTIONS ON REVERSE SIDE)
ACCOUNT NO.
SOCIAL SECURITY NUMBER
(1) BUSINESS/PRINCIPAL IDENTIFICATION
(2) WORKER IDENTIFICATION
NAME (Print)
NAME (Print)
DBA
ADDRESS
ADDRESS
CITY, STATE, and ZIP
CITY, STATE, and ZIP
THIS PORTION TO BE COMPLETED BY THE WORKER
(5) Name and SSN as shown on the State of California Income
(3) TOTAL EARNINGS SUBJECT TO PERSONAL INCOME TAX WITHHOLDING
Tax Return(s) (Form 540 or 540NR) for the year(s) listed in
Item (3).
YEAR
_________________________________________
Your Name
Reported on W2
______________ – ________ – ________________
SSN
_____________________________________
Spouse’s Name
Additional Earnings
1st Qtr.
______________ – ________ – ________________
SSN
2nd Qtr.
Current address if different from Item (2) above.
3rd Qtr.
____________________________________________________
4th Qtr.
____________________________________________________
Total Additional Earnings
(6) I reported the following earnings from this entity on my
California Income Tax Return(s): (NOTE: If your total income
Total Earnings
received for any of the indicated years was insufficient to require
a California Income Tax Return, write NR in the box for that year).
(4) COMPUTATION OF TAX DUE (See Instructions)
YEAR
YEAR
Earnings
1st qtr
If you paid taxes prior to your April 15th deadline, please complete
2nd qtr
the following section.
3rd qtr
I paid the following estimate(s) (Form 540ES):
4th qtr
YEAR
TOTALS
04/15
06/15
(8) BUSINESS/PRINCIPAL CERTIFICATION
09/15
01/15
I certify that to the best of my knowledge and belief the signature in
Item (7) is valid and legal.
I paid the following amount(s) with my 540 or 540NR:
The tax in Item (4) was based upon a valid Employee’s Withholding
YEAR
Allowance Certificate (copy attached) that was in my possession at the
time of the payment of the earnings shown in Item (3).
Amount
A completed worksheet is attached.
Date Paid
The tax in Item (4) was calculated based upon the worker being single
(7) Under penalty of perjury, I certify that the information shown in
with no deductions. A completed worksheet is attached.
Items (5) & (6) above is true and correct.
Signature of Worker
Date
Signature of Business/Principal Representative
Date
RETURN TO:
DATE STAMP
DE 938P Rev. 11 (11-01) (INTERNET)
CU
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