Looking for a California Tax Forms And Templates? Download it for free!

YEAR

Additional Taxes on Qualified Plans (Including IRAs)

CALIFORNIA FORM

2001

3805P

and Other Tax-Favored Accounts

For calendar year 2001 or

fiscal year beginning month________ day________ year 2001, and ending month________ day________ year________ .

First name

Last name

Your social security number

nitial

Present home address (number and street or rural route)

Apt. no.

PMB no.

Check this box if this

is an amended return

City, town, or post office

State

ZIP Code

Tax on Early Distributions – Complete this part if a taxable distribution was made from your qualified retirement plan (including an IRA other than

Part I

an education (Ed) IRA), annuity contract, or modified endowment contract before you reached age 59½ (or was incorrectly indicated as such on

your Form 1099-R – see instructions).

1 Early distributions included in gross income. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1 _________________

. . . . . . . . . . .

2 Distributions not subject to additional tax. See instructions. Enter exception number from instructions

2 _________________

3 Amount subject to additional tax. Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3 _________________

4 Tax due. Multiply line 3 by 2½% (.025). Enter here and on Form 540, line 36 or Long Form 540NR, line 45. If you are not

required to file a California income tax return, sign this form below and refer to the instructions . . . . . . . . . . . . . . . . . . . . . . . . .

4 _________________

Caution: If any part of the amount on line 3 was a distribution from a SIMPLE IRA, you may have to include 6% (.06) of that amount on line 4 instead of 2½%

(.025). See instructions.

Part II Tax on Distributions from Ed IRAs Not Used for Educational Expenses – Complete this part if a distribution was made from your Ed IRA

and was not used for educational expenses.

5 Taxable amount from federal Form 8606, line 30. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5 _________________

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6 Distributions not subject to additional tax. See instructions

6 _________________

7 Amount subject to additional tax. Subtract line 6 from line 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7 _________________

8 Tax due. Multiply line 7 by 2½% (.025). Enter here and on Form 540, line 36 or Long Form 540NR, line 45. If you are not

. . . . . . . . . . . . . . . . . . . . .

required to file a California income tax return, sign this form below and refer to the instructions

8 _________________

Part III Tax on Distributions from Archer Medical Savings Accounts (MSAs) – Complete this part if you reported a taxable distribution from an MSA on

federal Form 8853.

9 Taxable MSA distribution from federal Form 8853, line 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9 _________________

10 a If you meet any of the exceptions to the 10% tax (see instructions), check here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10a

b Otherwise, multiply line 9 by 10% (.10). Enter the result here and include it in the total on

Form 540, line 36, or Long Form 540NR, line 45. If you are not required to file a California income

tax return, sign this form below and refer to the instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10b _________________

11 Additional tax due from Medicare+Choice MSA distributions. Enter the amount from federal Form 8853, line 15b on this line.

Also include this amount in the total on Form 540, line 36, or Long Form 540NR, line 45. If you are not required to file a California

income tax return, sign this form below and refer to the instructions. Long Form 540NR filers, see instructions . . . . . . . . . . . . . .

11_________________

Signature. Complete only if you are filing this form by itself and not with your tax return.

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. It is unlawful to forge a spouse’s signature.

Your signature

Date

Signature of paid preparer ( declaration of preparer is based on all information of which preparer has any knowledge.)

Paid preparer’s SSN/FEIN/PTIN

Firm’s name (or yours if self-employed) and address

Date

3805P01104

FTB 3805P

2001

For Privacy Act Notice, get form FTB 1131.