DE 945 ANNUAL INCOME REPORT FOR DISABILITY INSURANCE ELECTIVE COVERAGE THIS IS NOT A BILL YEAR YEAR ENDED DUE DIEC Account Number Social Security Number DEPT. USE ONLY DO NOT ALTER THIS AREA Mo. EFFECTIVE DATE = Day = Yr. = The net profit or loss reported for the calendar year shown above will be used to determine your quarterly premiums for the following year. Those premiums will determine your benefits for future years. 1. Enter the new profit from line 3 of your IRS Schedule SE in this box. (Please attach a copy of your Schedule SE to this form.) OR 2. If you did not file an IRS Schedule SE, enter the net profit or loss from your IRS Schedule C, F, or K-1. (Please attach a copy of the appropriate schedule to this form.) $ Net Profit from IRS Schedule SE, C, F, or K-1 Note: The name and social security number on your schedule(s) must agree with those preprinted on this form. If you have been granted a filing extension by the IRS, please DO NOT submit this form until you file your tax return. BE SURE TO SIGN THIS DECLARATION: I DECLARE that the information herein is true and correct to the best of my knowledge and belief. Signature Title Phone ( ) Date / / THIS IS NOT A BILL PLEASE DO NOT SEND PAYMENTS WITH THIS FORM. DE 945 Rev. 3 (12-05) (INTERNET) P.O. Box 826880 / MIC 5 / Sacramento, CA 94280-0001 Page 1 of 2 CU-PA218 American LegalNet, Inc. www.FormsWorkflow.com INFORMATION REGARDING THE DE 945, ANNUAL INCOME REPORT FOR DISABILITY INSURANCE ELECTIVE COVERAGE Sections 708 and 708.5 of the California Unemployment Insurance Code require that you provide an annual statement of your net profit as reported to the Internal Revenue Service (IRS) for the prior tax year. If your taxes are filed with IRS on a fiscal year basis, please provide the fiscal year end date and the date by which IRS requires the information to be filed if no extension is requested. This information will assist the Department in posting your annual income to the correct period for premium and benefit purposes. Fiscal Year End Date / / Date Due to IRS / / Failure to sign and submit this form may result in reduction of future disability insurance benefits. Assistance in completing this form may be obtained by calling (916) 654-6288 or our Employment Tax Customer Service Representative at 1-888-745-3886. For TTY (non verbal) access, call 1-800-547-9565. DE 945 Rev. 3 (12-05) (INTERNET) Page 2 of 2 CU-PB218 American LegalNet, Inc. www.FormsWorkflow.com
|
Get this form for FREE as a print-only pdf
