California Form 592 Draft - Resident And Nonresident Withholding Statement

Resident and Nonresident

TAXABLE YEAR

CALIFORNIA FORM

2016

592

Withholding Statement

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Amended

Prior Year Distribution

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April 15, 2016

June 15, 2016

September 15, 2016

January 15, 2017

Due Date:

Part I Withholding Agent

FEIN

CA Corp no.

CA SOS file no.

Business name

SSN or ITIN

First name

Initial Last name

Address (apt./ste., room, PO box, or PMB no.)

City (If you have a foreign address, see instructions.)

State

ZIP code

Total Number of Payees

Part II Type of Income

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Check all that apply.

Payments to Independent Contractors

Distributions to Domestic Nonresident

Elective Withholding

Trust Distributions

Partners/Members/Beneficiaries/

Elective Withholding by Indian Tribe

Rents or Royalties

S Corporation Shareholders

Other______________________

Estate Distributions

Part III Tax Withheld

1 Total tax withheld from Schedule of Payees, excluding backup withholding

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(Side 2 and any additional pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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2 Total backup withholding (Side 2 and any additional pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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3 Add line 1 and line 2. This is the total amount of tax withheld . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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4 Enter amounts of prior payments not previously distributed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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5 Enter amount withheld by another entity and being distributed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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6 Add line 4 and line 5. This is the total amount of payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7 Total Withholding Amount Due. Subtract line 6 from line 3. Remit the withholding payment with

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Form 592-V, along with Form 592. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

To learn about your privacy rights, how we may use your information, and the consequences for not providing the requested information, go to ftb.ca.gov and

search for privacy notice. To request this notice by mail, call 800.852.5711.

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. Declaration of preparer (other than withholding agent) is based on all information of which preparer has any knowledge.

Print or type withholding agent's name

Telephone

Sign

(

)

Withholding agent's signature

Date

Here

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Print or type preparer’s name

Preparer's PTIN

Preparer’s signature