California Form 592 - Resident And Nonresident Withholding Statement - 2012 Page 2
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4Withholding Agent (Payer) Name: _____________________________ Withholding Agent ID No.:__________________
Schedule of Payees
PRINT CLEARLY
Business name
m SSN or ITIN m FEIN m CA Corp no. m SOS file no.
First name
Last name
Initial
m
If backup withholding, check the box.
DBA (if applicable)
Address (suite, room, PO Box, or PMB no.)
City
State
ZIP Code
Total income
Amount of tax withheld
.
.
00
00
,
,
,
,
Business name
m SSN or ITIN m FEIN m CA Corp no. m SOS file no.
First name
Last name
Initial
m
If backup withholding, check the box.
DBA (if applicable)
Address (suite, room, PO Box, or PMB no.)
City
State
ZIP Code
Total income
Amount of tax withheld
.
.
,
,
00
,
,
00
Business name
m SSN or ITIN m FEIN m CA Corp no. m SOS file no.
First name
Initial
Last name
m
If backup withholding, check the box.
DBA (if applicable)
Address (suite, room, PO Box, or PMB no.)
City
State
ZIP Code
Total income
Amount of tax withheld
.
.
,
,
00
,
,
00
Business name
m SSN or ITIN m FEIN m CA Corp no. m SOS file no.
First name
Last name
Initial
m
If backup withholding, check the box.
DBA (if applicable)
Address (suite, room, PO Box, or PMB no.)
City
State
ZIP Code
Total income
Amount of tax withheld
.
.
,
,
00
,
,
00
Total Income and Withholding For This Page Only
Notice to Withholding Agents: We require the total amounts below to be calculated and submitted for each page.
Total Income
Total California Tax Withheld Excluding
Total Backup Withholding
Backup Withholding
.
.
.
00
,
,
00
,
,
,
,
00
Side 2 Form 592
2011
C3
7082123
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