CLAIM FOR REFUND OF EXCESS CALIFORNIA STATE
DISABILITY INSURANCE DEDUCTIONS
DO NOT FILE THIS CLAIM FOR REFUND UNLESS YOU ARE EXEMPT FROM CALIFORNIA STATE INCOME TAX. PLEASE COMPLETE A
SEPARATE FORM FOR EACH INDIVIDUAL.
First Name and Middle Initial
Social Security Number
Current Home Address (Number and Street, including apartment number, or rural route)
For Tax Year:
City, Town or Post Office, State, and ZIP Code
Complete schedule below if you worked for two or more employers and deductions for California State Disability Insurance (SDI)
exceeded the amount shown in Column 7(D) below.
ACTUAL DEDUCTION FOR
WAGES PAID TO YOU
SDI, NOT TO EXCEED
DO NOT SHOW MORE
SHOWN IN COLUMN 7(B)
EMPLOYER’S BUSINESS NAME AND CITY
THAN THE AMOUNT
OF WAGES SHOWN IN
AS SHOWN ON FORM W-2
SHOWN IN COLUMN 7(C)
COLUMN (C). DO NOT
(List in Alphabetical Order)
FOR ANY ONE EMPLOYER.
LIST FICA DEDUCTIONS.
*Copies of Form(s) W-2 must be attached.
3. Total DI taxable wages paid
4. Total actual deductions for SDI (includes Paid Family Leave amount)
5. Enter amount shown in Column 7(D) for tax year
6. Refund claimed (line 4 less line 5)
TABLE OF MAXIMUM WAGES AND REQUIRED CONTRIBUTIONS
(A) Tax Year
(B) Percentage Rate
(C) Maximum Wages
(D) Maximum Contributions
8. I hereby declare that I am exempt from California State Income Tax and, therefore, am filing this claim directly with the Employment
I further declare under penalty of perjury that the statement of wages paid to me and contributions deducted, as shown hereon, are
true and correct to the best of my knowledge and belief.
CONTACT PHONE NUMBER
*This request cannot be processed without copies of Form(s) W-2. The Form(s) W-2 will not be returned.
DE 1964 Rev. 32 (12-16) (INTERNET)
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