DE945ANNUALINCOMEREPORTFOR                                        
                                                                           DISABILITYINSURANCEELECTIVECOVERAGE                                             

                                                             THISISNOTABILL       
                                                                                                                                                        YEAR 
YEARENDED                                                  DUE 

                                                                                                                             DIECAccountNumber            

                                                                                                                              SocialSecurityNumber           
                                                                                                               DONOTALTERTHISAREA                              

                                                                                                ONLY

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

Thenetprofitorlossreportedforthecalendaryearlistedabovewillbeusedtodetermineyourquarterlypremiums                                                             
andbenefitsforfutureyears.Pleaseseethe                DisabilityInsuranceElectiveCoverage(DIEC)RateNoticeand                               
InstructionsforComputingAnnualPremiums                  (DE3D-I)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,pleaseDONOTsubmitthis                                                    
       formuntilyoufileyourtaxreturn.               

BESURETOSIGNTHISDECLARATION:IDECLAREthattheinformationhereinistrueandcorrecttothebestof                                                                    
myknowledgeandbelief.          

Signature_______________________________________       Title________________________________        Phone(         )___________    Date____/____/____         

                                                        THISISNOTABILL.       

                                 PLEASEDONOTSENDPAYMENTSWITHTHISFORM.                                              

                                              P.O.Box826880/MIC5/Sacramento,CA94280-0001                       

DE945Rev.6(11-13)      (INTERNET)                               Page1of2                                                                                 CU 

                         INFORMATIONREGARDINGTHE                ANNUALINCOMEREPORTFOR                
                               DISABILITYINSURANCEELECTIVECOVERAGE                     (DE945)  

Sections708and708.5of     theCaliforniaUnemploymentInsuranceCoderequireparticipantstoprovideacopyof                       
theirannualincomestatementofnetprofitorlossasreportedtotheIRSforthepriortaxyeartotheEDD.                            

IfyourtaxfilingperiodwiththeIRSisnotbasedonacalendaryear(January1toDecember31),pleaseprovide                            
yourtaxperiodendingdateandtheduedatereportedwiththeIRSforfilingyourtaxes.Thisinformationwillassist                         
theEDD inpostingyourannual     incometothecorrect     periodforpremiumandbenefit     determinationpurposes.            

       TaxYearEndDate_____/_____/                                  DateDuetoIRS_____      /_____/_____           

Pleasesubmitthisformpostmarkedbytheduedateindicatedonthetopofthefirstpage.Failuretotimelysubmit                          
thissignedformwiththerequestedinformationwithoutgoodcausemayresultinreceivingdelinquencynotices                         
andpotentiallyimpactyourfutureDisabilityInsurancebenefits.           

Forassistanceincompletingthisform,pleasecall916-654-6288ortheTaxpayerAssistanceCenterat                         
888-745-3886.ForTTY      (non-verbal)access,call800-547-9565.        

DE945Rev.6(11-13)      (INTERNET)                            Page2of2