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