California Form 592 - Quarterly Resident And Nonresident Withholding Statement - 2009
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1
2Quarterly Resident and Nonresident
TAXABLE YEAR
CALIFORNIA FORM
Withholding Statement
2009
592
m
Amended
.
00
,
,
FTB Use Only: Total Payment Enclosed:
m
m
m
m
April 15, 2009
June 15, 2009
September 15, 2009
January 15, 2010
Payment Due Date:
Part I Withholding Agent
Name of Withholding Agent (Payer)
SSN or ITIN
Address (including suite, room, PO Box, or PMB no.)
FEIN or CA Corp no.
City
State
ZIP Code
.
00
,
,
Total Number of Payees Included
Total California Source Income Subject to Withholding
Part II Type of Income
Check one type only.
m
m
m
A
Payment to Independent Contractor
D
Rents or Royalties
F
Estate Distributions
m
m
m
B
Payment to Independent Contractor
E
Distributions to Domestic Nonresident
G
Other________________________
Entertainers/Athletes/Speakers
Partners/Members/Beneficiaries/
m
C
Trust Distributions
S Corporation Shareholders
.
,
,
00
1 Total Tax Withheld (Side 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
.
00
,
,
2 Total Tax Withheld (Side 2 and any additional pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
.
00
,
,
3 Add line 1 and line 2. This is the total Tax Withheld . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
.
,
00
,
4 Enter amounts of prior payments not previously distributed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
.
00
,
,
5 Enter amount withheld by another entity and being distributed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
.
00
,
,
6 Add line 4 and line 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
.
00
,
,
7 Total Withholding Amount Due. Subtract line 6 from line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
Schedule of Payees
ID Number
ID Type
Total Income
Amount of Tax Withheld
m
m
m
SSN or ITIN
FEIN
CA Corp no.
Name
Address (including suite, room, PO Box, or PMB no.)
ID Number
ID Type
Total Income
Amount of Tax Withheld
m
m
m
SSN or ITIN
FEIN
CA Corp no.
Name
Address (including suite, room, PO Box, or PMB no.)
.
00
,
,
Total Tax Withheld this page . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Part III Perjury Statement
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and
belief, it is true, correct, and complete. Declaration of preparer (other than withholding agent) is based on all information of which preparer has any knowledge.
( )
Withholding Agent’s name ______________________________________________
Withholding Agent’s daytime phone number ______________________
Withholding Agent’s signature ______________________________________________________________________________________________________
Preparer’s name ______________________________________________________
Preparer’s signature ________________________________________
Preparer’s address _______________________________________________________________________________________________________________
( )
Preparer’s SSN/PTIN __________________________________________________
Preparer’s phone daytime phone number ________________________
Form 592
2008 Side 1
7081093
For Privacy Notice, get form FTB 1131.
C3
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