DE 1964 Rev. 39 (12-23)
Claim for Refund of Excess California State
Disability Insurance Deductions
Do not le a claim for a refund with the Employment Development Department unless you are not required to le a California personal
income tax return with the Franchise Tax Board (FTB) for the year in question. If you are required to le a California personal income tax
return with the FTB for the year you are requesting a refund, you must claim your refund on your California personal income tax return led
with the FTB. Please complete a separate form for each individual.
1.
Type or
Print
First Name and Middle Initial Last Name Social Security Number
Current Home Address (Number and Street, Including Apartment Number, or Rural Route) For Tax Year
City, Town or Post Oce, State, and ZIP Code Date Filed
Complete this schedule if you worked for two or more employers, and deductions for California State Disability Insurance (SDI) exceeded
the amount shown in column 7(D). If California SDI was withheld from your wages by a single employer at more than the amount shown in
column 7(D) below, contact the employer for a refund.
2.
Wage Summary
Employer’s Business Name and City
as shown on Form W-2
(List in alphabetical order)
*Copies of W-2 forms must be attached.
Dates employed
during calendar
year
Wages paid to you
during
Do not show more
than the amount
shown in column 7(C)
for any one employer
Actual deduction for
SDI, not to exceed
percentage rate
shown in column 7(B)
of wages shown in
column (C). Do not
list FICA deductions.
Column (A) Column (B) Column (C) Column (D)
Name Location From (Month) To (Month) Dollars Cents Dollars Cents
3. Total Disability Insurance 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 (subtract Line 4 from Line 5)
7. Table of Maximum W ages and Required Contributions
(A) Tax Year (B) Percentage Rate (C) Maximum Wages (D) Maximum Contributions
2020 1.0% 122,909 1,229.09
2021 1.2% 128,298 1,539.58
2022 1.1% 145,600 1,601.60
2023 0.9% 153,164 1,378.48
8. I hereby declare that I am exempt from California state income tax and not required to le a California state income tax return, therefore,
I am ling 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 Date
Contact Phone Number Contact Email
*This request cannot be processed without copies of your W-2 forms. The copies of your W-2 forms will not be returned.
CU
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(INTERNET)
Instructions
Claim for Refund of Excess California State
Disability Insurance Deductions
Claim Must Be Based on Calendar Year Wages
A valid State Disability Insurance (SDI) refund claim led directly with the Employment Development Department (EDD) 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 be exempt from California state income tax and not required to le a California state income tax
return.
Where to File Claim
Employment Development Department, PO Box 826880, Special Processes Group MIC 100, Sacramento, CA 94280-0001.
When to File Claim
Claims for credit or refund of California SDI overpayment must be led 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 marked as “Amended” (if not, they will be returned to claimant) and forwarded to:
Employment Development Department, PO Box 826880, Special Processes Group MIC 100, Sacramento, CA 94280-0001
Information for Completing Wage Summary Schedule
1. The SDI deductions are shown on W-2 forms, employer 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 W-2 forms.
Column (B) – The calendar year dates employed by employer in column (A).
Column (C) – Wages paid up to annual maximum wages in section 7(C) paid to you by each column (A)
employers.
Column (D) – 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 for all employers listed in column (C).
4. Enter total of all SDI deductions withheld for all employers listed in column (D). You must attach copies of W-2 forms verifying
SDI amounts withheld, or a statement from the employer indicating the amount of SDI withheld.
5. Enter maximum contribution for the corresponding tax year (see column 7D).
6. Enter amount of refund claimed (subtract Line 4 from 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 and not required to le a California
state income tax return. 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 our EDD’s Excess State Disability Insurance Unit by calling 1-916-654-8333
or mailing a letter to the address listed above.
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DE 1964 Rev. 39 (12-23) (INTERNET)