California Form 3805p - Additional Taxes On Qualified Plans (Including Iras) And Other Tax-Favored Accounts - 2004

YEAR

Additional Taxes on Qualified Plans (Including IRAs)

CALIFORNIA FORM

2004

3805P

and Other Tax-Favored Accounts

For calendar year 2004 or

fiscal year beginning month________ day________ year 2004, and ending month________ day________ year________ .

First name

I

Last name

Your social security number

nitial

-

-

Present home address (number and street or rural route)

Apt. no.

PMB no.

Check this box if this

is an amended return

State

City, town, or post office

ZIP Code

-

Part I

Additional Tax on Early Distributions – Complete this part if you took a taxable distribution, before you reached age 59½, from a qualified retirement

plan (including an IRA) or modified endowment contract. You also may have to complete this part if you received a Form 1099-R that incorrectly

indicates an early distribution or you received a Roth IRA distribution (see instructions).

1 Early distributions included in income. For Roth IRA distributions, see instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1 _________________

2 Early distributions included on line 1 that are not subject to additional tax. See instructions. Enter the appropriate exception

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

number from instructions

2 _________________

3 Amount subject to additional tax. Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3 _________________

4 Tax due. Multiply line 3 by 2½% (.025). Enter here and on Form 540, line 36 or Long Form 540NR, line 45. If you are not

required to file a California income tax return, sign this form below and refer to the instructions . . . . . . . . . . . . . . . . . . . . . . . . .

4 _________________

Caution: If any part of the amount on line 3 was a distribution from a SIMPLE IRA, you may have to include 6% (.06) of that amount on line 4 instead of 2½%

(.025). See instructions.

Part II Additional Tax on Distributions from Coverdell Education Savings Accounts (ESAs) or a Qualified Tuition Program (QTP) Not Used for Educational

Expenses – Complete this part if a distribution was made from your Coverdell ESA or QTP and was not used for educational expenses.

5 Distributions included in income from Coverdell ESAs or QTPs from federal Publication 970, Tax Benefit for Education,

Worksheet 7-3, line 16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5 _________________

. . . . . . . . . . . . . . . . . . . . . . . . . . . .

6 Distributions included on line 5 that are not subject to additional tax. See instructions

6 _________________

7 Amount subject to additional tax. Subtract line 6 from line 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7 _________________

8 Tax due. Multiply line 7 by 2½% (.025). Enter here and on Form 540, line 36 or Long Form 540NR, line 45. If you are not

. . . . . . . . . . . . . . . . . . . . .

required to file a California income tax return, sign this form below and refer to the instructions

8 _________________

Part III Additional Tax on Distributions from Archer Medical Savings Accounts (MSAs) – Complete this part if you reported a taxable distribution from an

MSA on federal Form 8853.

9 Taxable Archer MSA distribution from federal Form 8853, Archer MSAs and Long-Term Care Insurance Contracts, line 10 . . . .

9 _________________

10 a If you meet any of the exceptions to the 10% tax (see instructions), check here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10a

b Otherwise, multiply line 9 by 10% (.10). Enter the result here and include it in the total on

Form 540, line 36 or Long Form 540NR, line 45. If you are not required to file a California income

tax return, sign this form below and refer to the instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10b _________________

11 Additional tax due from Medicare+Choice MSA distributions. Enter the amount from federal Form 8853, line 15b on this line.

Also include this amount in the total on Form 540, line 36 or Long Form 540NR, line 45. If you are not required to file a California

income tax return, sign this form below and refer to the instructions. Long Form 540NR filers, see instructions . . . . . . . . . . . . .

11_________________

Signature. Complete only if you are filing this form by itself and not with your tax return.

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. It is unlawful to forge a spouse’s signature.

Your signature

Date

X

Signature of paid preparer ( declaration of preparer is based on all information of which preparer has any knowledge.)

Paid preparer’s SSN/PTIN

Firm’s name (or yours if self-employed) and address

FEIN

3805P04104

FTB 3805P

2004

C1

For Privacy Act Notice, get form FTB 1131.