Form 540nr Draft - California Nonresident Or Part-Year Resident Income Tax Return - 2016 Page 3

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Your name: ______________________________________Your SSN or ITIN: ______________________________
121 AMOUNT YOU OWE. Add line 104 and line 120. See instructions. Do Not Send Cash.
.
,
,
00
Mail to: FRANCHISE TAX BOARD, PO BOX 942867, SACRAMENTO CA 94267-0001 . . . . . . . . . . . . . . .
121
Pay Online – Go to ftb.ca.gov for more information.
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,
,
00
125 REFUND OR NO AMOUNT DUE. Subtract line 120 from line 103. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
125
Mail to:
FRANCHISE TAX BOARD
PO BOX 942840
SACRAMENTO CA 94240-0001
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 instructions
Have you verified the routing and account numbers? Use whole dollars only.
All or the following amount of my refund (line 125) is authorized for direct deposit into the account shown below:
Checking
.
00
,
,
Savings
Routing number
Type
Account number
126 Direct deposit amount
The remaining amount of my refund (line 125) is authorized for direct deposit into the account shown below:
Checking
.
00
,
,
Savings
Routing number
Type
Account number
127 Direct deposit amount
To learn about your privacy rights, how we may use your information, and the consequences for not providing the requested information, go to
ftb.ca.gov and search for privacy notice. To request this notice by mail, call 800.852.5711.
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
Date
Spouse’s/RDP’s signature (if a joint tax return, both must sign)
X
X
Your email address. Enter only one email address.
Preferred phone number
Sign
(
)
Here
Paid preparer’s signature (declaration of preparer is based on all information of which preparer has any knowledge)
I
t is unlawful to
forge a
spouse’s/RDP’s
Firm’s name (or yours, if self-employed)
PTIN
signature.
Joint tax return?
(See instructions)
Firm’s address
FEIN
Do you want to allow another person to discuss this tax return with us? See instructions. . . . .
Yes
No
Print Third Party Designee’s Name
Telephone Number
(
)
3143163
Short Form 540NR C1 2016 Side 3

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