
Form 540 C1 2012 Side 33103123
115 REFUND OR NO AMOUNT DUE. Subtract line 95 and line 110 from line 93 (see page 17).
Mail to: FRANCHISE TAX BOARD, PO BOX 942840, SACRAMENTO CA 94240-0001 ...........
115
Fill in the information to authorize direct deposit of your refund into one or two accounts. Do not attach a voided check or a deposit slip (see page 17).
Have you verified the routing and account numbers? Use whole dollars only.
All or the following amount of my refund (line 115) is authorized for direct deposit into the account shown below:
Checking
Savings
Routing number Type Account number 116 Direct deposit amount
The remaining amount of my refund (line 115) is authorized for direct deposit into the account shown below:
Checking
Savings
Routing number Type Account number 117 Direct deposit amount
111 AMOUNT YOU OWE. Add line 94, line 95, and line 110 (see page 15). Do not send cash.
Mail to: FRANCHISE TAX BOARD, PO BOX 942867, SACRAMENTO CA 94267-0001 .......... 111
Pay online – Go to ftb.ca.gov for more information.
Your name: __________________________________ Your SSN or ITIN: ____________________________
Amount
You Owe
Refund and Direct Deposit Interest and
Penalties
.
,
,
00
.
,
,
00
.
,
,
00
.
,
,
00
112 Interest, late return penalties, and late payment penalties...........................................112 00
113 Underpayment of estimated tax. Check the box: FTB 5805 attached FTB 5805F attached ....... 113 00
114 Total amount due (see page 17). Enclose, but do not staple, any payment ..............................114 00
Your signature Spouse’s/RDP’s signature Daytime phone number (optional)
(if a joint tax return, both must sign)
X X Date
IMPORTANT: See the instructions to find out if you should attach a copy of your complete federal tax return.
Under penalties of perjury, I declare that I have examined this tax return, including accompanying schedules and statements, and to the best of my
knowledge and belief, it is true, correct, and complete.
Paid preparer’s signature (declaration of preparer is based on all information of which preparer has any knowledge)
Firm’s name (or yours, if self-employed) Firm’s address
PTIN
(
)
FEIN
Sign
Here
I
t is unlawful
to forge a
spouse’s/RDP’s
signature.
Joint tax return?
(see page 17)
Do you want to allow another person to discuss this tax return with us? (see page 17) ......... Yes No
__________________________________________________________________ __________________________________
Print Third Party Designee’s Name Telephone Number
( )
Your email address (optional). Enter only one email address.
Contributions
110 Add code 400 through code 423. This is your total contribution ................................... 110 00
Code Amount
California Seniors Special Fund (see page 23) ....
400 00
Alzheimer’s Disease/Related Disorders Fund .....
401 00
California Fund for Senior Citizens .............
402 00
Rare and Endangered Species
Preservation Program.....................
403 00
State Children’s Trust Fund for the Prevention
of Child Abuse...........................
404 00
California Breast Cancer Research Fund .........
405 00
California Firefighters’ Memorial Fund ..........
406 00
Emergency Food for Families Fund .............
407 00
California Peace Officer Memorial
Foundation Fund .........................
408 00
Code Amount
California Sea Otter Fund ....................
410 00
Municipal Shelter Spay-Neuter Fund............
412 00
California Cancer Research Fund ..............
413 00
ALS/Lou Gehrig’s Disease Research Fund........
414 00
Child Victims of Human Trafficking Fund ........
419 00
California YMCA Youth and Government Fund ....
420 00
California Youth Leadership Fund ..............
421 00
School Supplies for Homeless Children Fund .....
422 00
State Parks Protection Fund/Parks Pass Purchase
423 00