ANNUALINCOMEREPORTFORDISABILITY                                        
                                                                                  INSURANCEELECTIVECOVERAGE                                   

                                                                   THISISNOTA        BILL    
                                                                                                                                                       YEAR 
YEARENDED                                                       DUE 

                                                                                                                                   DIECACCOUNTNUMBER            

                                                                                                                                     LASTFOURDIGITSOF          
                                                                                                                                   SOCIALSECURITYNUMBER           
                                                                                                                       DONOTALTERTHISAREA                        

                                                                                                       ONLY

                                                                                                                                   Mo.    Day  Yr. 
                                                                                                                       EFFECTIVE 
                                                                                                           DEPT.USE       DATE      =     =    = 

Thenetprofitorlossreportedforthecalendaryearlistedabovedeterminesyourquarterlypremiumsandbenefits                                                             
forfutureyears.Pleaseseethe                DisabilityInsuranceElectiveCoverage(DIEC)RateNoticeandInstructionsfor                                        
Computing Annual Premiums                 (DE3DI-I)(PDF)        (edd.ca.gov/pdf_pub_ctr/de3dii.pdf) forfurtherinformation.                           

1.Enterthenetprofitorlossfromline3ofyourInternalRevenueService(IRS)ScheduleSE                                                      $ 
  inthisbox.    (Pleaseattachacopyof       yourScheduleSEtothisform.)                     
                                                                                                                                 NETPROFIT<LOSS>FROMIRS        
                                                                                                                                 SCHEDULESE,C,F,ORK-1        
                                        OR 

2.   IfyoudidnotfileanIRSScheduleSE,                       enterthenetprofitorloss       
  fromyourIRSScheduleC,                      F, orK-1.    
  (Pleaseattachacopyof             theappropriatescheduletothisform.)               

Note: ThenameandthelastfourdigitsofyourSocialSecuritynumberonyourschedules(s)mustagreewith                                                            
        thosepreprintedonthisform.IftheIRShasgrantedyouafilingextension,please                                              donot    submitthis     
        formuntilyoufileyourtaxreturn.                     

BESURETOSIGNTHISDECLARATION:IDECLAREthattheinformationhereinistrueandcorrecttothebestof                                                                   
myknowledgeandbelief.                 

Signature_______________________________________              Title________________________________        Phone(          )___________    Date____/____/____  

                                                              THISISNOTABILL.         

                                       PLEASEDONOTSENDPAYMENTSWITHTHISFORM.                                                

                                                      POBox826880/MIC5/Sacramento,CA94280-0001                        

DE945Rev.7(3-20)            (INTERNET)                                Page1of2                                                                               CU 

                                INFORMATIONREGARDINGTHE              ANNUALINCOMEREPORTFOR                
                                       DISABILITYINSURANCEELECTIVECOVERAGE                   (DE945)  

Sections708and708.5ofthe               CaliforniaUnemploymentInsuranceCode            (leginfo.legislature.ca.gov/faces/codes.xhtml) 
requireparticipantstoprovideacopyoftheirannualincomestatementofnetprofitorlossasreportedtotheIRS                                     
forthepriortaxyeartotheEmploymentDevelopmentDepartment(EDD).                               

IfyourtaxfilingperiodwiththeIRSisnotbasedonacalendaryear(January1toDecember31),pleaseprovide                                     
yourtaxperiodendingdateandtheduedatereportedwiththeIRSforfilingyourtaxes.Thisinformationwillassist                                     
theEDDinpostingyourannualincometothecorrectperiodforpremiumandbenefitdeterminationpurposes.                                     

     TaxYearEndDate_____/_____/_____                                    DateDuetoIRS_____        /_____/_____           

Pleasesubmitthisformpostmarkedbytheduedateindicatedonthetopofthefirstpage.Failuretotimelysubmit                                       
thissignedformwiththerequestedinformationwithoutgoodcausemayresultinreceivingdelinquencynotices                                  
andpotentiallyimpactyourfutureDisabilityInsurancebenefits.                

Forassistanceincompletingthisform,pleasecall1-916-654-6288ortheTaxpayerAssistanceCenterat                                 
1-888-745-3886.ForTTY             (non-verbal)access,call1-800-547-9565.            

TheEDDisanequalopportunityemployer/program.Auxiliaryaidsandservicesareavailableuponrequestto                                   
individualswithdisabilities.Requestsforservices,aids,and/oralternateformatsneedtobemadebycalling                             
1-888-745-3886(voice)orTTY1-800-547-9565.                  

DE945Rev.7(3-20)            (INTERNET)                            Page2of2