Form De 1964 - Claim For Refund Of Excess California State Disability Insurance Deductions - Ca Employment Development Dept.
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3CLAIM 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. IF HUSBAND AND WIFE
BOTH QUALIFY, COMPLETE A SEPARATE FORM FOR EACH SPOUSE.
First Name and Initial
Last Name
Social Security Number
1.
PLEASE
Present Home Address (Number and Street, including apartment number, or rural route)
For Tax Year:
TYPE
OR
PRINT
City, Town or Post Office, State and ZIP Code
Date Filed
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
WAGE SUMMARY
DURING _______
DATES EMPLOYED
PERCENTAGE RATE
DO NOT SHOW MORE
DURING CALENDAR
SHOWN IN COLUMN 7(B)
EMPLOYER’S BUSINESS NAME AND CITY
THAN THE AMOUNT
YEAR ______
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
COLUMN (A)
COLUMN (B)
COLUMN (C)
COLUMN (D)
NAME
LOCATION
FROM (MONTH)
TO (MONTH)
DOLLARS
CENTS
DOLLARS
CENTS
2.
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)
7.
TABLE OF MAXIMUM WAGES AND REQUIRED CONTRIBUTIONS
(A) Tax Year
(B) Percentage Rate
(C) Maximum Wages
(D) Maximum Contributions
.5% (1-01-2000 to 3-31-2000)
*
2000
46,327
324.29
.7% (4-01-2000 to 12-31-2000)
2001
.9%
46,327
416.94
2002
.9%
46,327
416.94
2003
.9%
56,916
512.24
For the year 2000 only:
Due to the year 2000 having multiple percentage rates, you will need to complete the attached Excess SDI Worksheet to calculate
your Excess California State Disability Insurance Deductions.
8.
I hereby declare that I am exempt from California State Income Tax and therefore am filing this claim directly with the Employment
Development Department.
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.
SIGNATURE
DATE
DE 1964 Rev. 19 (1-04) (INTERNET)
Page 1 of 3
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