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Your name:

Your SSN:

Payments Complete this part before completing Side 1, line 23.

Part I

a Amount paid with the original return. Do not include payments of interest or penalties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1a _________________

b Enter the serial number stamped on the face of your canceled check (if available) . . . . . 1b _________________________

Additional payments made after the original return was filed:

Enter in the spaces below the date of the payment(s), the serial number stamped on the face of your canceled check(s) by the Franchise Tax Board, and

the amount(s) of additional payment(s). If you did not receive a canceled check or make any payment(s) with a credit card, enter the payment amount(s)

below and attach a copy of the statement from your financial institution showing the:

Check number (if applicable);

Amount of the check or charge; and

Date the check or charge posted to your account.

Payment date

Serial number

Amount of payment

Total of additional payments listed above . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 _______________

Total payments. Add line 1a and line 2. Enter here and on Side 1, line 23 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 _______________

Part II Explanation of Changes

Enter name and address as shown on original return below (if same as shown on this return, write “Same”). If changing from

separate returns to a joint return, enter names and addresses from original returns._____________________________________________________

____________________________________________________________________________________________________________________

Yes

a If you filled in the circle for “Yes,” on Side 1, question a, are you filing this Form 540X to report a final federal determination? . . . . . . . . .

b If the answer to question 2a above is “Yes,” are you filing this Form 540X to report additional tax due within six months of the final

federal determination? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

c If the answer to question 2a above is “Yes,” what is the date and tax change amount of the final federal determination?

Date ______________________________________________________ Tax change amount _____________________________________________

Have you been advised that your original California return has been, is being, or will be audited? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

Did you file an amended return with the Internal Revenue Service on a similar basis? See General Information E . . . . . . . . . . . . . . . . . . . . . .

Yes

Explain your changes to income, deductions, and credits in the space provided below. Enter the line number from Side 1 for each item you are changing.

Attach all supporting forms and schedules for items changed. Include federal schedules if you made a change to your federal return. Be sure to include

your name and social security number on each attachment. Refer to the tax booklet for the year you are amending.

Under penalties of perjury, I declare that I have filed an original return and that I have examined this amended return including accompanying

schedules and statements and to the best of my knowledge and belief, this amended return is true, correct, and complete.

Your signature

Daytime phone number

Sign

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Here

Spouse’s signature (if filing joint, both must sign)

It is unlawful to

Date