Form 540nr - California Nonresident Or Part-Year Resident Income Tax Return - 2012 Page 3
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1
2
3Your name: ______________________________________Your SSN or ITIN: ______________________________
Code
Amount
Code
Amount
California Sea Otter Fund . . . . . . . . . . . . . . . . . . . . 410
00
California Seniors Special Fund (see page 23) . . . . 400
00
Municipal Shelter Spay-Neuter Fund . . . . . . . . . . . . 412
00
Alzheimer’s Disease/Related Disorders Fund . . . . . 401
00
California Cancer Research Fund . . . . . . . . . . . . . . 413
00
California Fund for Senior Citizens . . . . . . . . . . . . . 402
00
ALS/Lou Gehrig’s Disease Research Fund . . . . . . . . 414
00
Rare and Endangered Species
Child Victims of Human Trafficking Fund . . . . . . . . 419
00
Preservation Program . . . . . . . . . . . . . . . . . . . . . 403
00
California YMCA Youth and Government Fund . . . . 420
00
State Children’s Trust Fund for the Prevention
California Youth Leadership Fund . . . . . . . . . . . . . . 421
00
of Child Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . 404
00
School Supplies for Homeless Children Fund . . . . . 422
00
California Breast Cancer Research Fund . . . . . . . . . 405
00
State Parks Protection Fund/Parks Pass Purchase 423
00
California Firefighters’ Memorial Fund . . . . . . . . . . 406
00
Emergency Food for Families Fund . . . . . . . . . . . . . 407
00
California Peace Officer Memorial
Foundation Fund . . . . . . . . . . . . . . . . . . . . . . . . . 408
00
120 Add code 400 through code 423 . This is your total contribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
120
00
121 AMOUNT YOU OWE. Add line 104 and line 120 (see page 24) . 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 .
122 Interest, late return penalties, and late payment penalties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
00
123 Underpayment of estimated tax . Check the box:
FTB 5805 attached
FTB 5805F attached . . . . . .
123
00
124 Total amount due (see page 25) . Enclose, but do not staple, any payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
00
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 25) . 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
Savings
.
00
,
,
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 numbe
127 Direct deposit amount
r
IMPORTANT: Attach a copy of your complete federal return.
Under penalties of perjury, I declare that I have examined this tax return, including accompanying schedules and statements, and to the best of my
knowledge and belief, it is true, correct, and complete.
Your signature
Spouse’s/RDP’s signature
Daytime phone number (optional)
(if a joint tax return, both must sign)
(
)
Sign
Here
X
X
Date
Your email address (optional) . Enter only one email address .
It is unlawful
Paid preparer’s signature (declaration of preparer is based on all information of which preparer has any knowledge)
PTIN
to forge a
spouse’s/RDP’s
signature .
Firm’s name (or yours, if self-employed)
Firm’s address
FEIN
Joint tax return?
(see page 25)
Do you want to allow another person to discuss this tax return with us? (see page 25) . . . . . . . . .
Yes
No
(
)
__________________________________________________________________
__________________________________
Print Third Party Designee’s Name
Telephone Number
Long Form 540NR
2012 Side 3
3133123
C1
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