Form 540 C1 - Draft - California Resident Income Tax Return - 2012 Page 5
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1
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5Your name:
Your SSN or ITIN:
111 AMOUNT YOU OWE. Add line 94, line 95, and line 110 (see page 15). Do not send cash.
Mail to: FRANCHISE TAX BOARD
PO BOX 942867
.
SACRAMENTO CA 94267-0001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
111
,
,
00
Pay online – Go to ftb.ca.gov for more information.
.
112 Interest, late return penalties, and late payment penalties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .112
00
00
m
m
.
00
113 Underpayment of estimated tax. Check the box:
FTB 5805 attached
FTB 5805F attached
113
.
114 Total amount due (see page 17). Enclose, but do not staple, any payment . . . . . . . . . . . . . . . . . . . . . . . . . .114
00
115 REFUND OR NO AMOUNT DUE. Subtract line 95 and line 110 from line 93 (see page 17).
Mail to: FRANCHISE TAX BOARD
PO BOX 942840
.
,
,
SACRAMENTO CA 94240-0001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
115
00
17).
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
Have you verified the routing and account numbers? Use whole dollars only.
All or the following amount of my refund (line 115) is authorized for direct deposit into the account shown below:
Type
m
Routing number
Checking
Account number
116 Direct deposit amount
m
.
,
,
00
Savings
The remaining amount of my refund (line 115) is authorized for direct deposit into the account shown below:
Type
m
Routing number
Checking
Account number
117 Direct deposit amount
m
.
,
,
00
Savings
IMPORTANT: See the instructions to find out if you should attach a copy of your complete federal tax 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
Date
Spouse’s/RDP’s signature (if a joint tax return, both must sign)
X
X
Your email address (optional). Enter only one email address.
Daytime phone number (optional)
Sign
(
)
Here
Paid preparer’s signature (declaration of preparer is based on all information of which preparer has any knowledge)
It is unlawful
to forge a
spouse’s/RDP’s
Firm’s name (or yours, if self-employed)
PTIN
signature.
Joint tax return?
Firm’s address
FEIN
(see page 17)
m
m
Do you want to allow another person to discuss this tax return with us? (see page 17) . . . . . .
Yes
No
Print Third Party Designee’s Name
Telephone Number
(
)
Form 540
2012 Side 5
3105123
C1
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