DE 945 ANNUAL INCOME REPORT FOR
DISABILITY INSURANCE ELECTIVE COVERAGE
THIS IS N OT A BILL
YEAR ENDED DUE
YEAR
DIEC Account Number
Social Security Number
DO NOT ALTER THIS AREA
Mo. Day Yr.
= =
=
EFFECTIVE
DATE
DEPT. USE ONLY
The net profit or loss reported for the calendar year listed above will be used to determine your quarterly premiums
and benefits for future years. Please see the Disability Insurance Elective Coverage (DIEC) Rate Notice and
Instructions for Computing Annual Premiums (DE 3D-I) for further information.
1. Enter the net profit or loss from line 3 of your Internal Revenue Service (IRS) Schedule SE
in this box. (Please attach a copy of your Schedule SE to this form.)
OR
$
Net Profit <Loss> from IRS
Schedule SE, C, F, or K-1
2. If you did not file an IRS Schedule SE, enter the net profit or loss
from your IRS Schedule C, F, or K-1.
(Please attach a copy of the appropriate schedule to this form.)
Note: The name and the last f our digits of your Social Security Number on your schedules(s) m ust agree with
those preprinted on this form. If the IRS has granted you a filing extension, please DO NOT submit this
form until you file your tax return.
BE SURE TO SIGN THIS DECLARATION: I DECLARE that the information herein is true and correct t o the best of
my knowledge and belief.
Signature _______________________________________ Title ________________________________ Phone ( ) ___________ Date ____/____/____
THIS IS N OT A BILL.
PLEASE DO NOT SEND PAYMENTS WITH THIS FORM.
P.O. Box 826880 / MIC 5 / Sacramento, CA 94280-0001
DE 945 Rev. 6 (11-13) (INTERNET) Page 1 of 2 CU
