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. Day Yr. EFFECTIVE DATE = = = The net profit or loss reported for the calendar year listed above will be used to determine your quarterly premiums and benefits for future years. Please see the Disability Insurance Elective Coverage (DIEC) Rate Notice and Instructions for Computing Annual Premiums (DE 3D-I) for further information. 1. Enter the net profit or loss from line 3 of your Internal Revenue Service (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 the last four digits of your Social Security Number on your schedules(s) must agree with those preprinted on this form. If the IRS has granted you a filing extension, 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. P.O. Box 826880 / MIC 5 / Sacramento, CA 94280-0001 DE 945 Rev. 6 (11-13) (INTERNET) Page 1 of 2 CU American LegalNet, Inc. www.FormsWorkFlow.com INFORMATION REGARDING THE ANNUAL INCOME REPORT FOR DISABILITY INSURANCE ELECTIVE COVERAGE (DE 945) Sections 708 and 708.5 of the California Unemployment Insurance Code require participants to provide a copy of their annual income statement of net profit or loss as reported to the IRS for the prior tax year to the EDD. If your tax filing period with the IRS is not based on a calendar year (January 1 to December 31), please provide your tax period ending date and the due date reported with the IRS for filing your taxes. This information will assist the EDD in posting your annual income to the correct period for premium and benefit determination purposes. Tax Year End Date _____ / _____ / _____ Date Due to IRS _____ / _____ / _____ Please submit this form postmarked by the due date indicated on the top of the first page. Failure to timely submit this signed form with the requested information without good cause may result in receiving delinquency notices and potentially impact your future Disability Insurance benefits. For assistance in completing this form, please call 916-654-6288 or the Taxpayer Assistance Center at 888-745-3886. For TTY (non-verbal) access, call 800-547-9565. DE 945 Rev. 6 (11-13) (INTERNET) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com