Edd Form De 1964 – Fill Out and Use This PDF

CLAIM FOR REFUND OF EXCESS CALIFORNIA STATE

DISABILITY INSURANCE DEDUCTIONS

DO NOT FILE THIS CLAIM FOR REFUND UNLESS YOU ARE EXEMPT FROM CALIFORNIA STATE INCOME TAX. PLEASE COMPLETE A SEPARATE FORM FOR EACH INDIVIDUAL.

Complete schedule below if you worked for two or more employers and deductions for California State Disability Insurance (SDI) exceeded the amount shown in Column 7(D) below.

				WAGES PAID TO YOU		ACTUAL DEDUCTION FOR
	WAGE SUMMARY					SDI, NOT TO EXCEED
		DATES EMPLOYED		DURING	________
						PERCENTAGE RATE
				DO NOT SHOW MORE
		DURING CALENDAR
	EMPLOYER’S BUSINESS NAME AND CITY					SHOWN IN COLUMN 7(B)
				THAN THE AMOUNT
		YEAR	_______
	AS SHOWN ON FORM W-2					OF WAGES SHOWN IN
				SHOWN IN COLUMN 7(C)
	(List in Alphabetical Order)					COLUMN (C). DO NOT
				FOR ANY ONE EMPLOYER
	*Copies of Form(s) W-2 must be attached.					LIST FICA DEDUCTIONS
	COLUMN (A)	COLUMN (B)		COLUMN (C)		COLUMN (D)
NAME	LOCATION	FROM (MONTH)	TO (MONTH)	DOLLARS	CENTS	DOLLARS	CENTS

2.

	3.	Total DI taxable wages paid
	4.	Total actual deductions for SDI (includes Paid Family Leave amount)
	5.	Enter amount shown in Column 7(D) for tax year
	6.	Refund claimed (line 4 less line 5)
7.		TABLE OF MAXIMUM WAGES AND REQUIRED CONTRIBUTIONS
(A) Tax Year		(B) Percentage Rate	(C) Maximum Wages		(D) Maximum Contributions
2009		1.1%	90,669		997.36
2010		1.1%	93,316		1026.48
2011		1.2%	93,316		1119.79
2012		1.0%	95,585		955.85
2013		1.0%	100,880		1008.80

8.I hereby declare that I am exempt from California State Income Tax and, therefore, am filing this claim directly with the Employment Development Department.

I further declare under penalty of perjury that the statement of wages paid to me and contributions deducted, as shown hereon, are true and correct to the best of my knowledge and belief.

SIGNATURE

PHONE NUMBER

DATE

*This request cannot be processed without copies of Form(s) W-2. The Form(s) will not be returned.

DE 1964 Rev. 29 (12-13) (INTERNET)

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INSTRUCTIONS

CLAIM FOR REFUND OF EXCESS CALIFORNIA STATE

DISABILITY INSURANCE DEDUCTIONS

CLAIM MUST BE BASED ON CALENDAR YEAR WAGES

A valid SDI refund claim filed directly with the Employment Development Department on this form must meet ALL of the following conditions:

1.Claimant worked for two or more employers subject to withholding California SDI.

2.Deductions for California SDI were made from calendar year wages.

3.Such deductions exceed the statutory limits.

4.Claimant declares by signature to exemption from California State Income Tax.

WHERE TO FILE CLAIM:

Employment Development Department, P.O. Box 826880, Special Processes Group MIC 13, Sacramento, CA 94280-0001.

WHEN TO FILE CLAIM:

Claims for credit or refund of California SDI overpayment must be filed within three years after the end of the calendar year in which the excess deductions were made. The claim must be based on the calendar year in which the wages were received.

AMENDED CLAIMS:

Amended claims must be so marked (if not, they will be returned to claimant) and forwarded to the Employment Development Department, P.O. Box 826880, Special Processes Group MIC 13, Sacramento, CA 94280-0001.

INFORMATION FOR COMPLETING WAGE SUMMARY SCHEDULE:

1.The SDI deductions are shown on Forms W-2, employer's statements, and check stubs.

2.Most federal, state, and local government agencies are not required to deduct California SDI. Do not include these wages in your claim unless disability insurance deductions were actually made.

3.Do not include in your claim:

a.Deductions made from your wages for Social Security and Medicare (FICA), or federal and state income tax withheld from your wages.

b.Deductions made from wages earned in states other than California, unless such wages were reported to the State of California.

c.Seaman's wages that come under the jurisdiction of states other than California.

4.Self-employed Persons – Enter in Column (A) "Covered under California Unemployment Insurance Code Section 708 or 708.5" and complete Column (B). Failure to enter this information will result in rejection of your claim on initial review.

INSTRUCTIONS FOR COMPLETING DE 1964

1.Enter all information requested in section 1.

2.Enter employer information:

Column (A) – All employers and location of job sites, attach Form(s) W-2. Column (B) – The calendar year dates employed by employer in Column (A).

Column (C) – Wages up to annual maximum shown in Section 7(C) paid to you by individual Column (A) employers. Column (D) – Enter actual amount of SDI withheld. Do not exceed the percentage rate shown in Section 7(B) of wages in

Column (C).

3.Enter total SDI taxable wages paid.

4.Enter total of all SDI deductions withheld by each employer in Column (D). This amount must be verified by attached Form W-2 copies showing SDI amounts withheld or a statement from the employer indicating the amount of SDI withheld.

5.Enter maximum contribution for tax year (see Column 7D).

6.Enter amount of refund claimed (line 4 less line 5).

7.Table of Maximum Wages and Required Contributions (reference table only).

8.Read and sign this declaration which states you are exempt from California State Income Tax. Without your signature, your claim will be rejected.

9.Enter your phone number and date.

ASSISTANCE:

If you need assistance in completing this claim, contact the Excess State Disability Insurance Unit of the Employment Development Department, P.O. Box 826880, Special Processes Group MIC 13, Sacramento, CA 94280-0001, 916-654-8333.

DE 1964 Rev. 29 (12-13) (INTERNET)

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