Auditor’s Name   _______________________________
                                                                                  Phone Number  ________________________________
                                                                                  Assessment #   _________________________________
                                                                                  Case #  _______________________________________

CLAIM FOR ADJUSTMENT OR REFUND OF PERSONAL INCOME TAX

                                                     Account Number                                                          Social Security Number (SSN)
 (1)  Business/Principal Identification                                          (2) Worker Identification
   Name (Print)                                                                    Name (Print)
   DBA                                                                             Address
   Address                                                                         City, State, ZIP Code
   City, State, ZIP Code                                                          
                                                                                 This Portion to Be Completed by the Worker
 (3)  Total Earnings Subject to Personal Income Tax Withholding                  (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).
  Calendar Year               
 Reported on Form W-2                                                                        Your Name _________________________________________
                                                                                             Your SSN __________ – ________ – ________________
 Additional Earnings                                                                         Spouse’s Name _____________________________________
   1st Quarter
                                                                                             Spouse’s SSN __________ – ________ – _____________
  2nd Quarter
                                                                                             Current address, if different from Item (2) above.
  3rd Quarter
                                                                                  ____________________________________________________
  4th Quarter
                                                                                  ____________________________________________________
 Total Additional Earnings
                                                                                 (6)  I reported the following earnings from this entity on my 
 Total Earnings                                                                              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 
 (4)  Computation of Tax Due (Refer to Instructions)                                         that year.)
 Calendar Year                                                                               Year           
 1st Quarter                                                                      Earnings

 2nd Quarter                                                                     If you paid taxes prior to the April 15 deadline, please complete 
                                                                                 the following section.
 3rd Quarter
                                                                                 I paid the following estimate(s) (Form 540ES):
 4th Quarter
                                                                                             Year              
  Totals                                                                          04/15
 (8)  Business/Principal Certification                                            06/15
                                                                                  09/15
         I certify that to the best of my knowledge and belief, the signature in 
         Item (7) is valid and legal.                                             01/15
                                                                                 I paid the following amount(s) with my Form 540 or Form 540NR:
         The tax in Item (4) was based upon a valid Employee’s Withholding 
         Allowance Certificate (copy attached) that was in my possession at the              Year              
         time of the payment of the earnings shown in Item (3).
         A completed worksheet is attached.                                       Amount
                                                                                  Date Paid
         The tax in Item (4) was calculated based upon the worker being single 
         with no deductions. A completed worksheet is attached.                  (7)  Under penalty of perjury, I certify that the information shown      
                                                                                     in Items (5) and (6) above is true and correct.

  Signature of Business/Principal Representative                Date             Signature of Worker                            Date

                                        Return To:                                                Date Stamp

DE 938P Rev. 12 (5-13) (INTERNET)                                                Page 1 of 2                                                               CU

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                 Original and one (1) copy of the DE 938P should be sent to the audit office shown on 
Deliver               page 1 of this form.

DE 938P Rev. 12 (5-13) (INTERNET)                  Page 2 of 2