When you are preparing your tax return, it is important to have all of the necessary forms. One of the most common forms is Form E3065. This form is used to report taxable pensions and annuities. If you receive a pension or annuity, you will need to know whether or not it is taxable. This form can help you determine that. In order to complete the form correctly, you will need to know which parts of the pension or annuity are taxable. There are many factors that go into determining if a pension or annuity is taxable, so be sure to gather all of the necessary information before completing the form.
Here is some data that might be beneficial if you are trying to find out how much time it will take you to fill out form e3065 and just how many PDF pages it contains.
| Question | Answer |
|---|---|
| Form Name | Form E3065 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | state fund mileage claim form, scif form e3065, state compensation insurance fund california medical mileage expense form, scif mileage form |
Please mail to your assigned claims adjuster provided on your claim correspondence or mail to one of these State Fund Claims Processing Centers:
P.O. Box 65005 Fresno, CA 93650
P.O. Box 3171 Suisun City, CA 94585
Injured's Name / Nombre de la Persona Lesiónada
Claim Number / Número de Reclamo
Medical Mileage Expense Form
Forma de Gastos por Distancia Recorrida por Visitas Médica
You are entitled to reimbursement of medical travel expense incurred because of your industrial injury. Complete this form to request reimbursement of medical travel expense. Mileage rates are different depending on the day you traveled. We will calculate the total due using the miles traveled. Please see example below. California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Please note: Mileage for reasonable travel to the pharmacy, parking, bridge tolls, and public transportation costs should also be included. Attach receipts and send this form to State Compensation Insurance Fund. Keep a copy for your records.
Rate For Travel / Tarifa Para Viajes
01/01/2019 - Current |
58.0 cents/centavos |
01/01/2013 - 12/31/2013 |
56.5 cents/centavos |
01/01/2018 - 12/31/2018 |
54.5 cents/centavos |
07/01/2011 - 12/31/2012 |
55.5 cents/centavos |
01/01/2017 - 12/31/2017 |
53.5 cents/centavos |
01/01/2011 - 06/30/2011 |
51.0 cents/centavos |
01/01/2016 - 12/31/2016 |
54.0 cents/centavos |
01/01/2010 - 12/31/2010 |
50.0 cents/centavos |
01/01/2015 - 12/31/2015 |
57.5 cents/centavos |
01/01/2009 - 12/31/2009 |
55.0 cents/centavos |
01/01/2014 - 12/31/2014 |
56.0 cents/centavos |
07/01/2008 - 12/31/2008 |
58.5 cents/centavos |
Usted tiene derecho a recibir reembolso por gastos de viaje por visitas médicas incurridos debido a la lesión sufrida en el trabajo. Llene este formulario para solicitar el reembolso de gastos de viaje médicos. Las tarifas para millaje son diferentes según el día que usted viajó. Vamos a calcular el total adeudado usando las millas que usted viajó. Por favor, vea el ejemplo abajo. Las leyes de
California establecen que la siguiente declaración aparezca en este formulario: Cualquier persona que a sabiendas presente reclamos falsos o fraudulentos para el pago de una pérdida, será culpable de un delito y se le podría multar y encarcelar en la penitenciaría estatal.
Por favor de notar: Millaje razonable para viajar a la farmacia, aparcamiento, peajes de puentes, los costos del transporte público también debería incluirse. Adjuntar recibos y envíe este formulario a State Compensation Insurance Fund. Guarde una copia para sus archivos.
Date / |
Traveled from |
|
Traveled to (include name and address of |
|
Round trip |
For State Fund |
||||
Fecha |
(include address) |
|
doctor, hospital, therapist, etc.) |
|
mileage/ |
Use: |
||||
|
Viaje desde |
|
Viaje a (incluya nombre y dirección del |
|
Millaje de Ida y |
|
||||
|
(incluya dirección) |
|
medico, hospital, terapeuta, etc.) |
|
Vuelta |
|
||||
Example |
1515 Maple, |
|
Dr. Sherman, 190 Oak, |
|
|
14 mi x .58 c |
||||
Ejemplo |
|
|
|
|||||||
San Francisco |
|
San Francisco |
|
14 mi |
= $ 8.12 |
|||||
1/1/19 |
|
|
||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Total Parking and/or Tolls (attach receipts) |
|
|
|
|
|
|
||||
Estacionamiento y/o Peaje (incluya recibos) |
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
|
|
||
|
|
Total Public Trans / Other |
|
|
|
|
|
|
||
|
Transporte Público / Otros Total |
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
SIGNATURE / FIRMA |
|
|
|
|
|
TOTAL |
||||
|
|
|
|
REIMBURSEMENT |
||||||
PRINT NAME / IMPRIMA SU NOMBRE |
|
|
|
|
|
|||||
|
|
|
|
|
||||||
DATE / FECHA |
|
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
|
|
e3065 (REV.