Form De 370 - Statement Of Amount Due From Worker

ADVERTISEMENT

STATEMENT OF AMOUNT DUE FROM WORKER
CALIFORNIA DISABILITY INSURANCE (DI) CONTRIBUTIONS
AND PERSONAL INCOME TAX (PIT) ON REPORTED CASH TIPS
EMPLOYER
WORKER
ACCOUNT NUMBER
NAME
NAME
ADDRESS
ADDRESS
SOCIAL SECURITY NUMBER
1. PERIOD COVERED BY REPORT
FROM:___/___/___
TO: ___/___/___
2. Amount of Tips Reported by Worker
$ ___________
3. Amount of California DI Contributions due from Worker
$ ___________
[Cannot exceed DI rate in effect for year multiplied by item #2 above]
Amount of California Personal Income Tax due from Worker
$ ___________
4.
EMPLOYER CERTIFICATION
I hereby certify that this worker’s regular wages were insufficient to cover the withholding of
California disability insurance and personal income tax amounts shown as due. The worker
was given an opportunity to remit these amounts to the employer before this form was
submitted to the Employment Development Department.
________________________________
____________________
___/___/___
Preparer’s Signature
Title
Date
WORKER CERTIFICATION
I acknowledge the California tax liability shown above and declare that the information is true
and correct to the best of my knowledge.
________________________________
___/___/___
Worker’s Signature
Date
Submit entire document with payment to: Employment Development Department
P.O. Box 826880, MIC 25
Sacramento, CA 94280-0001
Please enter worker’s Social Security Number on the check.
DE 370 Rev. 5 (1-98) (INTERNET) State of California / Employment Development Department
CU
Page 1 of 2

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go