Form 540nr - California Nonresident Or Part-Year Resident Income Tax Return - 2009 Page 3
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1
2
3Your name: ______________________________________Your SSN or ITIN: ______________________________
Code
Amount
400
California Seniors Special Fund. See instructions (see page 21) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
00
401
Alzheimer’s Disease/Related Disorders Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
00
California Fund for Senior Citizens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
402
00
403
Rare and Endangered Species Preservation Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
00
404
State Children’s Trust Fund for the Prevention of Child Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
00
California Breast Cancer Research Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
405
00
California Firefighters’ Memorial Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
406
00
407
Emergency Food for Families Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
00
California Peace Officer Memorial Foundation Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
408
00
California Military Family Relief Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
409
00
410
California Sea Otter Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
00
411
California Ovarian Cancer Research Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
00
Municipal Shelter Spay-Neuter Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
412
00
413
California Cancer Research Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
00
414
ALS/Lou Gehrig’s Disease Research Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
00
105 . Add code 400 through code 414 . This is your total contribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
105 .
00
121 . AMOUNT .YOU .OWE. .Add line 104 and line 105 (see page 22) . Do .not .send .cash .
00
.
,
,
Mail to: FRANCHISE .TAX .BOARD, .PO .BOX .942867, .SACRAMENTO .CA .94267-0001 . . . . . . . . .
121
122 . Interest, late return penalties, and late payment penalties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 .
00
123 . Underpayment of estimated tax . Fill in the circle:
FTB .5805 .attached
FTB .5805F .attached . . . . . .
123 .
00
124 . Total amount due (see page 23) . Enclose, but do .not staple, any payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 .
00
125 . REFUND .OR .NO .AMOUNT .DUE. .Subtract line 105 from line 103 .
.
00
,
,
Mail to: FRANCHISE .TAX .BOARD, .PO .BOX .942840, .SACRAMENTO .CA .94240-0002 . . . . . . . . . .
125
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 page 23) . 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 numbe
127 .Direct deposit amount
r
Important: Attach a copy of your complete federal income tax return.
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.
Sign
Your signature
Spouse’s/RDP’s signature
Daytime phone number (optional)
(if a joint return, both must sign)
(
)
Here
X
X
Date
It is unlawful
Paid preparer’s signature (declaration .of .preparer .is .based .on .all .information .of .which .preparer .has .any .knowledge)
Paid preparer’s SSN/PTIN
to forge a
spouse’s/RDP’s
signature .
Firm’s name (or yours, if self-employed)
Firm’s address
FEIN
Joint return?
(see page 23)
Do you want to allow another person to discuss this return with us (see page 23)? . . . . . . . . . . . .
Yes
No
(
)
__________________________________________________________________
__________________________________
Print Third Party Designee’s Name
Telephone Number
Long Form 540NR
2009 Side .3
3133093
C1
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Parent category: Financial