Form De 938 - Quarterly Adjustment Form For Voluntary Plan Disability Insurance Employers - 2011
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1QUARTERLY ADJUSTMENT FORM FOR VOLUNTARY
PLAN DISABILITY INSURANCE EMPLOYERS
Instructions for completion are available on reverse side
For Quarter Ended
Employer Account No.
of this form. PRINT OR TYPE IN BLUE OR
MO.
DAY
YR.
BLACK INK ONLY.
STATUTE OF LIMITATIONS
For Department Use Only
A claim for refund or credit
Name
must be filed within three
MO.
DAY
YR.
years of the last timely
EFFECTIVE
DBA
filing date of the
DATE
Address
quarter being adjusted.
(1)
(2)
(3)
DIFFERENCES
I. ADJUSTMENT TO WAGES AND CONTRIBUTIONS
Previously reported
Should have reported
Debit/(Credit)
0.00
A. TOTAL SUBJECT WAGES.............................................................
0.00
B. UNEMPLOYMENT INSURANCE (UI) Taxable Wages...................
0.00
C1. VOLUNTARY PLAN DISABILITY INSURANCE (VPDI) WAGES ...
0.00
C2. STATE DISABILITY INSURANCE (SDI) Taxable Wages...............
0.00
0.00
0.00
D. EMPLOYER’S UI CONTRIBUTIONS (UI Rate
0.00
% times B) .....
0.00
0.00
0.00
E. EMPLOYMENT TRAINING TAX (ETT Rate
0.00
% times B) .........
0.00
0.00
0.00
F1. DI VOLUNTARY PLAN ASSESSMENT..........................................
(Vol. DI Assmt Rate
00.00% times C1)
0.00
0.00
0.00
F2. STATE DISABILITY INSURANCE* (SDI) Withheld (SDI Rate
0.00
% times C2; complete Box 1 below if credit on row F2.) .......
0.00
G. PERSONAL INCOME TAX (PIT) Withheld (Complete
Box 2 below if credit.).....................................................................
0.00
0.00
0.00
H. SUBTOTAL (Lines D, E, F1, F2, & G). ............................
0.00
I.
Penalty (Refer to instructions on reverse side)........................................................................................................
J. Interest (Refer to instructions on reverse side)........................................................................................................
K. Less Erroneous SDI Deductions not refunded (See Box 1 Line 2 below) ..............................................................
0.00
L. Total.........................................................................................................................................................................
*Includes Paid Family Leave amount.
BOX 1. STATE DISABILITY INSURANCE OVERPAYMENTS
(Must be completed for credit to be allowed.)
1. Was the credit claimed in column 3 withheld from the wages of employee(s)?.................................................................
Yes
No
If yes, has this amount been refunded to employee(s)? ....................................................................................................
Yes
No
2. Not refunded; employee(s) no longer employed, unable to locate. (List Social Security Number, employee name, last known address, and
amount of SDI not refunded on a separate page. Show the total on Line K above.)
BOX 2. PERSONAL INCOME TAX OVERPAYMENTS
(Must be completed for credit to be allowed.)
If you paid the Employment Development Department (EDD) more than the amount of California PIT withheld from wages of employee(s),
you can adjust the amount reported by using this form. The EDD will allow credit adjustments prior to the issuance of Forms W-2. If you
have already issued Forms W-2, please read the additional information on page 2 before proceeding.
1. Was the credit claimed in column 3 withheld from the pay of employee(s)? .....................................................................
Yes
No
If yes, has this credit been refunded to employee(s)? .......................................................................................................
Yes
No
2. Was the credit claimed in column 3 included on Forms W-2 issued to employee(s)? .......................................................
Yes
No
II. REASON FOR ADJUSTMENT
III. EMPLOYEE WAGES/PIT WITHHOLDINGS ADJUSTMENT Enter the correct information which should have been reported.
Enter only those employees whose wages, withholdings, or social security account numbers are being corrected. If you are reporting
adjustments for more than three (3) employees, list the items on a separate page with the same format or use a Quarterly Contribution
Return and Report of Wages (Continuation) (DE 9C).
SOCIAL SECURITY
EMPLOYEE NAME
TOTAL WAGES SHOULD
TOTAL STATE PIT SHOULD
ACCOUNT NUMBER
First Initial
Last Name
HAVE BEEN REPORTED
HAVE BEEN REPORTED
Total of this page OR total for all pages attached
IV.
.
I declare that the above information is true and correct to the best of my knowledge and belief. This section must be completed for credit to be allowed
SIGNATURE
TITLE (Owner, Accountant, Preparer, etc.)
TELEPHONE
DATE
X
(
)
DE 938 Rev. 43 (4-11)
(INTERNET)
P.O. Box 826880 / Sacramento CA 94280-0001
Page 1 of 2
CU
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