California Form 3525 - Substitute For Form W-2, Wage And Tax Statement, Or Form 1099-R, Distributions From Pensions, Annuities, Retirement Or Profit-Sharing Plans, Iras, Insurance Contracts, Etc.

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TAXABLE YEAR

CALIFORNIA FORM

Substitute for Form W-2, Wage and Tax Statement, or Form 1099-R,

Distributions From Pensions, Annuities, Retirement or Profit-Sharing

3525

Plans, IRAs, Insurance Contracts, Etc.

For Privacy Act Notice, see form FTB 1131. Attach this form to Form 540, Form 540A, Form 540EZ, Form 540NR or Form 540X.

1 Your first name and initial

Last name

2 Your social security number

3 Address (number, street, city, state and ZIP code)

4 PLEASE FILL IN THE YEAR AT THE END OF THIS STATEMENT: I have notified the Internal Revenue Service that I have been unable to obtain or have received an

incorrect Form W-2, Wage and Tax Statement, or Form 1099-R, Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts,

Etc., from my employer or payer named below.

The amounts shown below are my best estimates of all wages, tips, other compensation (including noncash payments), and retirement payments paid to me, and state

taxes and disability insurance withheld by this employer or payer during 19

5 Employer’s or payer’s name, address, state and ZIP Code

6 Federal employer identification number

7 State income tax withheld

8 Wages, tips, other compensation, or payments,

9 State Disability Insurance withheld

(if known)

(include the name of the state.)

before deductions for taxes, insurance, etc.

10 Dependent care benefits

11 Nonqualified plans

12 Gross disbributions – Qualified plan distributions