Auditor’s Name _______________________________
Phone Number ________________________________
Assessment # _________________________________
Case # _______________________________________
CLAIM FOR ADJUSTMENT OR REFUND OF PERSONAL INCOME TAX
(1) Business/Principal Identification
Account Number
Name (Print)
DBA
Address
City, State, ZIP Code
Social Security Number (SSN)
(2) Worker Identification
Name (Print)
Address
City, State, ZIP Code
(3) Total Earnings Subject to Personal Income Tax Withholding
Calendar Year
Reported on Form W-2
Additional Earnings
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
Total Additional Earnings
Total Earnings
(4) Computation of Tax Due (Refer to Instructions)
Calendar Year
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
Totals
(8) Business/Principal Certification
I certify that to the best of my knowledge and belief, the signature in
Item (7) is valid and legal.
The tax in Item (4) was based upon a valid Employee’s Withholding
Allowance Certificate (copy attached) that was in my possession at the
time of the payment of the earnings shown in Item (3).
A completed worksheet is attached.
The tax in Item (4) was calculated based upon the worker being single
with no deductions. A completed worksheet is attached.
Signature of Business/Principal Representative Date
DE 938P Rev. 12 (5-13)
(INTERNET) Page 1 of 2 CU
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This Portion to Be Completed by the Worker
(5) Name and SSN as shown on the State of California income
tax return(s) (Form 540 or Form 540NR) for the year(s) listed
in Item (3).
Your Name _________________________________________
Your SSN
Spouse’s Name
Spouse’s SSN
Current address, if different from Item (2) above.
(6)
I reported the following earnings from this entity on my
California income tax return(s): (NOTE: If your total income
received for any of the indicated years was insufficient to
require a California income tax return, write N/R in the box for
that year.)
Year
Earnings
If you paid taxes prior to the April 15 deadline, please complete
the following section.
I paid the following estimate(s) (Form 540ES):
Year
04/15
06/15
09/15
01/15
I paid the following amount(s) with my Form 540 or Form 540NR:
Year
Amount
Date Paid
(7) Under penalty of perjur
y, I certify that the information shown
in Items (5) and (6) above is true and correct.
Signature of Worker Date
Return To:
Date Stamp
INSTRUCTIONS FOR COMPLETING THE CLAIM FOR ADJUSTMENT OR REFUND OF PERSONAL INCOME TAX FORM
Purpose
To gain relief from some or all of the assessed Personal Income Tax (PIT) liability and
associated penalties and interest through the use of the DE 938P form.
Prior to completing this form, please refer to the Information Sheet: Personal Income Tax
Adjustment Process (DE 231W) for additional instructions.
Do not use this form to correct the earnings shown in Item (3) on page 1.
Instructions
Worker Instructions
1. Complete Item (5) showing name(s), Social Security Number(s), and your most
current address.
2. Complete Item (6) showing the amount of earnings reported on your California
income tax return from this business/principal for each of the indicated calendar years
and the amounts of all PIT payment(s) that were made prior to the April 15 deadline.
3. Sign and date Item (7). A signature is required.
Business/Principal Instructions
Instructions for Item (4):
If the worker completed a Form W-4/DE 4, which was on file at the time the earnings
were paid, you must use it as a basis for calculating the PIT that should have been
withheld and attach a copy of the Form W-4/DE 4 to this form. Otherwise, you must use
the single with no deductions (S/0) tax rate to calculate the PIT that should have been
withheld. Follow these steps:
1. Calculate the PIT for each pay period. Refer to the California Withholding Schedules
in the California Employer’s Guide (DE 44) for the applicable year.
2. Add up the PIT for all pay periods in each quarter. Enter the quarterly totals in the
corresponding box in Item (4) on page 1 of this form.
3. Add the quarterly totals to produce the annual total(s) in Item (4).
Instructions for Item (8):
Sign and date Item (8) (this form is not valid without this signature).
If you completed Item (4), indicate the basis for the PIT recalculations and furnish a
worksheet showing the recalculation.
Assistance
If you cannot secure the signatures of the worker(s) or recalculate the PIT, inform the
auditor.
Mail or
Deliver
Page 2 of 2
Original and one (1) copy of the DE 938P should be sent to the audit office shown on
page 1 of this form.
DE 938P Rev. 12 (5-13) (INTERNET)
