Form 540 - California Resident Income Tax Return - 2011 Page 3

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Your name: __________________________________ Your SSN or ITIN: ____________________________
Code
Amount
Code
Amount
California Sea Otter Fund . . . . . . . . . . . . . . . . . . . . 410
00
California Seniors Special Fund (see page 23) . . . . 400
00
Municipal Shelter Spay-Neuter Fund . . . . . . . . . . . . 412
00
Alzheimer’s Disease/Related Disorders Fund . . . . . 401
00
California Cancer Research Fund . . . . . . . . . . . . . . 413
00
California Fund for Senior Citizens . . . . . . . . . . . . . 402
00
ALS/Lou Gehrig’s Disease Research Fund . . . . . . . . 414
00
Rare and Endangered Species
Arts Council Fund . . . . . . . . . . . . . . . . . . . . . . . . . . 415
00
Preservation Program . . . . . . . . . . . . . . . . . . . . . 403
00
California Police Activities League
State Children’s Trust Fund for the Prevention
(CALPAL) Fund . . . . . . . . . . . . . . . . . . . . . . . . . . 416
00
of Child Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . 404
00
California Veterans Homes Fund . . . . . . . . . . . . . . . 417
00
California Breast Cancer Research Fund . . . . . . . . . 405
00
Safely Surrendered Baby Fund . . . . . . . . . . . . . . . . 418
00
California Firefighters’ Memorial Fund . . . . . . . . . . 406
00
Child Victims of Human Trafficking Fund . . . . . . . . 419
00
Emergency Food for Families Fund . . . . . . . . . . . . . 407
00
California Peace Officer Memorial
Foundation Fund . . . . . . . . . . . . . . . . . . . . . . . . . 408
00
110 Add code 400 through code 419 . This is your total contribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
110
00
111 AMOUNT YOU OWE. Add line 94, line 95, and line 110 (see page 15) . Do not send cash.
00
.
,
,
Mail to: FRANCHISE TAX BOARD, PO BOX 942867, SACRAMENTO CA 94267-0001 . . . . . . . . . .
111
Pay online – Go to ftb.ca.gov and search for web pay.
112 Interest, late return penalties, and late payment penalties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
00
113 Underpayment of estimated tax . Fill in circle:
FTB 5805 attached
FTB 5805F attached . . . . . . . . .
113
00
114 Total amount due (see page 16) . 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 16) .
00
.
,
,
Mail to: FRANCHISE TAX BOARD, PO BOX 942840, SACRAMENTO CA 94240-0002 . . . . . . . . . . .
115
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 17) .
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:
 Checking
00
.
,
,
 Savings
Routing number
Type
Account number
116 Direct deposit amount
The remaining amount of my refund (line 115) is authorized for direct deposit into the account shown below:
 Checking
00
.
,
,
 Savings
Routing number
Type
Account number
117 Direct deposit amount
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
Spouse’s/RDP’s signature
Daytime phone number (optional)
(if a joint tax return, both must sign)
(
)
Sign
Here
X
X
Date
Your email address (optional) . Enter only one email address .
It is unlawful
Paid preparer’s signature (declaration of preparer is based on all information of which preparer has any knowledge)
PTIN
to forge a
spouse’s/RDP’s
signature.
Firm’s name (or yours, if self-employed)
Firm’s address
FEIN
Joint tax return?
(see page 17)
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 C1 2011 Side 3
3103113
8

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