California Substitute for Form W-2, Wage and Tax Statement

Substitute for Form W-2, Wage and Tax Statement
2023 California Form 3525 Substitute for Form W-2, Wage and Tax Statement, or Form 1099-R, Distributions From Pensions, Annuities, Retirement or Profi
TAXABLE YEAR

Substitute for Form W-2, Wage and Tax Statement, or
Form 1099-R, Distributions From Pensions, Annuities,
Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc.

CALIFORNIA FORM

3525

Attach to original or amended Form 540, 540 2EZ, or 540NR.
1 Your first name, middle initial, and last name

2 Your SSN or ITIN

3 Address (number and street, apt., suite, PO box, or PMB no., city, state, and ZIP code)

4 ENTER THE YEAR IN THE SPACE PROVIDED AT THE END OF THIS STATEMENT: I notified the Internal Revenue Service that I have been unable to obtain or have
received an incorrect federal Form W-2, Wage and Tax Statement, or Form 1099-R, Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs,
Insurance Contracts, etc., from my employer or payer named below.
The amounts shown below are my best estimates of all wages, tips, other compensation (including noncash payments), retirement payments received, state income tax
withheld, and disability insurance withheld by the employer or payer during the __________ taxable year.
5 Employer’s or payer’s name, address, city, state, and ZIP code

6 Federal employer identification
number (if known)

7a State income tax withheld

10 Dependent care benefits

8 Wages, tips, or other compensation 9 State Disability Insurance withheld
before deductions for taxes,
insurance, etc.

7b Name of state

11 Nonqualified plans

12 Gross distribution – Qualified plan distributions
(IRA, pension, profit-sharing, etc.)

13 Taxable amount – Qualified plan distributions
(IRA, pension, profit-sharing, etc.)

14 Capital gain (included in box 13)

15 Other

16 How did you determine or estimate the amounts in items 7a–15? Attach a copy of your supporting documents, such as your last pay stub or pay statement for the tax year
showing the year-to-date totals.

17 Give the reason why federal Form W-2, Form 1099-R, or Form W-2c, Corrected Wage and Tax Statement, was not furnished by your employer or payer, if known. Explain
your efforts to obtain the form.

Sign
Here

Our privacy notice can be found in annual tax booklets or online. Go to ftb.ca.gov/privacy to learn about our privacy policy statement, or go to ftb.ca.gov/forms and search for
1131 to locate FTB 1131 EN-SP, Franchise Tax Board Privacy Notice on Collection. To request this notice by mail, call 800.338.0505 and enter form code 948 when instructed.
Under penalties of perjury, I declare that I have examined this statement and, to the best of my knowledge and belief, it is true, correct, and complete.
Date
Your signature

Instructions for Form FTB 3525

Substitute for Form W-2, Wage and Tax Statement, or Form 1099-R, Distributions From Pensions, Annuities,
Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc.
References in these instructions are to the Internal Revenue Code (IRC) as of January 1, 2015, and to the California Revenue and Taxation Code (R&TC).

General Information

Will I need to amend my tax return?

Purpose

If you receive a Form W-2, Form W-2c, or Form 1099-R, after your tax return
is filed with form FTB 3525, and the information differs from the information
reported on your tax return, you must amend your previously filed tax return.
See Instructions for Filing Amended Returns in the personal income tax
booklets.

Use form FTB 3525, Substitute for Form W-2, Wage and Tax Statement,
or Form 1099-R, Distributions From Pensions, Annuities, Retirement or
Profit-Sharing Plans, IRAs, Insurance Contracts, etc., as a substitute for
federal Forms W-2, W-2c, and 1099-R when your employer or payer does not
give you a Form W-2 or Form 1099-R, or when your employer or payer has
issued an incorrect Form W-2 or Form 1099-R. Attach form FTB 3525 to your
tax return.
You should always attempt to get Form W-2 or Form 1099-R from your
employer or payer before contacting the Internal Revenue Service (IRS) or
filing form FTB 3525. After February, you may call the IRS at 800.829.1040 if
you still have not received Form W-2 or Form 1099-R.
If you received an incorrect Form W-2 or Form 1099-R, you should always
attempt to have your employer or payer issue a corrected form before filing
form FTB 3525.
Note: Retain a copy of form FTB 3525 for your records.

Penalties
The Franchise Tax Board will challenge the claims of individuals who attempt
to avoid or evade their tax liability by using form FTB 3525 in a manner other
than as prescribed. Potential penalties for the improper use of form FTB 3525
include:
• Accuracy-related penalties equal to 20% of the amount of taxes that
should have been paid.
• Civil fraud penalties equal to 75% of the amount of taxes that should have
been paid.
• A civil penalty for filing a frivolous tax return or submitting a specified
frivolous submission as described by the California Revenue and Taxation
Code Section 19179 and Internal Revenue Code Section 6702.

8341233

FTB 3525 2023