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                                                       REPORT OF
                                         INDEPENDENT CONTRACTOR(S) 
                          See detailed instructions on reverse side. Please type or print.      05420101

SERVICE-RECIPIENT (BUSINESS OR GOVERNMENT ENTITY):
DATE                      FEDERAL ID NUMBER               CA EMPLOYER ACCOUNT NUMBER       SOCIAL SECURITY NUMBER

SERVICE-RECIPIENT NAME / BUSINESS NAME                                                     CONTACT PERSON

ADDRESS                                                                                    PHONE NUMBER

    CITY                                                                                   STATE              ZIP CODE 

    SERVICE-PROVIDER  (INDEPENDENT CONTRACTOR):
FIRST NAME                                             MI LAST NAME

SOCIAL SECURITY NUMBER               STREET NUMBER     STREET NAME                                                        UNIT/APT

CITY                                                                                       STATE       ZIP CODE

START  DATE  OF CONTRACT  AMOUNT OF CONTRACT                           CONTRACT EXPIRATION DATE  CHECK HERE IF CONTRACT IS ONGOING

    M M D D Y Y                        ,             ,    .                  M M D D Y  Y

FIRST NAME                                             MI LAST NAME

SOCIAL SECURITY NUMBER                 STREET NUMBER   STREET NAME                                                        UNIT/APT

CITY                                                                                       STATE       ZIP CODE

START  DATE  OF CONTRACT  AMOUNT OF CONTRACT                           CONTRACT EXPIRATION DATE  CHECK HERE IF CONTRACT IS ONGOING

    M M D D Y  Y                       ,             ,    .                  M M D D Y  Y

FIRST NAME                                             MI LAST NAME

SOCIAL SECURITY NUMBER                 STREET NUMBER   STREET NAME                                                        UNIT/APT

CITY                                                                                       STATE       ZIP CODE

START  DATE  OF CONTRACT  AMOUNT OF CONTRACT                           CONTRACT EXPIRATION DATE  CHECK HERE IF CONTRACT IS ONGOING

    M M D D Y  Y                       ,             ,    .                  M M D D Y  Y

                         MAIL TO:  Employment Development Department • PO Box 997350, MIC 96 • Sacramento, CA 95899-7350  
                                                       or Fax to 916-319-4410
     DE 542 Rev. 9 (6-17) (INTERNET)                        Page 1 of 2



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                                INSTRUCTIONS FOR COMPLETING ALL OF THE ELEMENTS ON THE 
                                  REPORT OF INDEPENDENT CONTRACTOR(S), DE 542

WHO MUST REPORT: 
Any business or government entity (defined as a “Service-Recipient”) that is required to file a federal Form 1099-MISC 
for service performed by an independent contractor (defined as a “Service-Provider”) must report. You must report to the 
Employment Development Department (EDD) within 20 days of EITHER making payments of $600 or more OR entering into a 
contract for $600 or more with an independent contractor in any calendar year, whichever is earlier. This information is used to 
assist state and county agencies in locating parents who are delinquent in their child support obligations.
An independent contractor is further defined as an individual who is not an employee of the business or government entity 
for California purposes and who receives compensation or executes a contract for services performed for that business or 
government entity either in or outside of California. For further clarification, request Information Sheet: Employment WorkStatus 
Determination, DE 231ES. See below for information on how to obtain additional forms.

YOU ARE REQUIRED TO PROVIDE THE FOLLOWING INFORMATION THAT APPLIES:
Service-Recipient (Business or Government Entity)                 Service-Provider (Independent Contractor)
Federal Employer Identification Number (FEIN)                   • First name, middle initial, and last name
California employer payroll tax account number                  • Social Security number (do not use FEIN)
  (if applicable)                                                 • Address
• Social Security number                                          Start date of contract (if no contract, date
• Service-recipient name/business name, address,                    payments equal $600 or more)
  and phone number                                                Amount of contract (including cents)
• Contact person                                                  Contract expiration date or check the box if the
                                                                    contract is ongoing
HOW TO COMPLETE THIS FORM:
If you use a typewriter or printer, ignore the boxes and type in UPPER CASE as shown. Do not use commas or periods.
  FIRST NAME                                          MI   LAST NAME
  IMOGENE                                             A      SAMPLE 
  SOCIAL SECURITY NUMBER          STREET NUMBER       STREET NAME                                               UNIT / APT.
  xxxxxxxxx                         12345         MAIN  STREET                                                      301

If you handwrite this form, print each letter or number in a separate box as shown. Do not use commas or periods. 
  FIRST NAME                                          MI  LAST NAME
  I  M  O  G  E  N  E                                A      S  A  M  P   L  E 
  SOCIAL SECURITY NUMBER          STREET NUMBER       STREET NAME                                               UNIT / APT.
   X  X  X  X  X  X  X  X  X         1  2  3  4  5     M  A  I  N     S T  R  E  E T                            3   0   1

ADDITIONAL INFORMATION:
If you have questions concerning the independent contractor reporting requirement, you may visit our web page at  
www.edd.ca.gov/Payroll_Taxes/Independent_Contractor_Reporting.htm, call the New Employee Registry and Independent 
Contractor Reporting at 916-657-0529, call the Taxpayer Assistance Center at 888-745-3886, or visit your local Employment Tax 
Office listed in the California Employer’s Guide, DE 44, and on our web page at  www.edd.ca.gov/Office_Locator/.

To obtain additional DE 542 forms:
Visit the EDD website at www.edd.ca.gov/Forms/.
For 25 or more forms, call 916-322-2835.
For less than 25 forms, call 916-657-0529 or call 888-745-3886.
HOW TO REPORT:
             For a fast, easy, and secure way to report your independent contractor information, use e-Services for Business. 
             For more information or to enroll, visit www.edd.ca.gov/e-Services_for_Business.
To file a paper DE 542 form, complete all of the information on the reverse side of this form and fax it to 916-319-4410 or 
mail it to:

EMPLOYMENT DEVELOPMENT DEPARTMENT
PO Box 997350, MIC 96  
Sacramento, CA 95899-7350
                                                                                                                            CU
DE 542 Rev. 9 (6-17) (INTERNET)                           Page 2 of 2






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