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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          YM D D 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          YM D D 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          YM D D 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 Work Status 
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 
                     (INTERNET)                               Page 2 of 2                                                            CU
DE 542 Rev. 9 (6-17) 






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