California Form 592 - Resident And Nonresident Withholding Statement - 2012

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TAXABLE YEAR
CALIFORNIA FORM
Resident and Nonresident Withholding Statement
2012
592
 m
 m
Amended
Prior Year Distribution
m
m
m
m
April 17, 2012
June 15, 2012
September 17, 2012
January 15, 2013
Due Date:
Part I Withholding Agent
m
m
m
m
  FEIN
  CA Corp no.
  SOS file no.
Business name
SSN or ITIN
First name
Initial Last name
Address (suite, room, PO Box, or PMB no.)
City
State
ZIP Code
Total Number of Payees
Part II Type of Income
Check all that apply.
m
m
m
A
D
F
Payment to Independent Contractor
Distributions to Domestic Nonresident
Elective Withholding
m
m
B
G
Trust Distributions
Partners/Members/Beneficiaries/
Elective Withholding/Indian Tribe
m
m
C
H
Rents or Royalties
S Corporation Shareholders
Other______________________
m
E
Estate Distributions
.
00
,
,
1 Total Withholding, excluding Backup Withholding (Side 2 and any additional pages) . . . . . . . . . . . . . . . . . . . .
1
.
00
,
,
2 Total Backup Withholding (Side 2 and any additional pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
.
00
,
,
3 Add line 1 and line 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
.
00
,
,
4 Enter amounts of prior payments not previously distributed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
.
00
,
,
5 Enter amount withheld by another entity and being distributed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
.
,
00
6 Add line 4 and line 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
,
7 Total Withholding Amount Due. Subtract line 6 from line 3. Remit the withholding payment with
.
00
,
,
Form 592-V, Payment Voucher for Resident and Nonresident Withholding, along with Form 592.. . . . . . . . . .
7
Part III Perjury Statement
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. Declaration of preparer (other than withholding agent) is based on all information of which preparer has any knowledge.
(
)
Withholding agent’s name ______________________________________________
Withholding agent’s daytime phone number ______________________
Withholding agent’s signature ______________________________________________________________ Date ____________________________________
Preparer’s name __________________________________________________________________________________________________________________
Preparer’s signature ______________________________________________________________________ Date ____________________________________
Preparer’s address ________________________________________________________________________________________________________________
(
)
Preparer’s PTIN/SSN __________________________________________________
Preparer’s daytime phone number _____________________________
Form 592
2011 Side 1
7081123
C3
For Privacy Notice, get form FTB 1131.

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