California Additional Taxes on Qualified Plans (Including IRAs) and Other Tax-Favored Accounts

Additional Taxes on Qualified Plans (Including IRAs) and Other Tax-Favored Accounts
2023 Form 3805P Additional Taxes on Qualified Plans (Including IRAs) and Other Tax-Favored Accounts
TAXABLE YEAR

2023
First name

Additional Taxes on Qualified Plans
(Including IRAs) and Other
Tax-Favored Accounts

CALIFORNIA FORM

3805P

Initial Last name

SSN or I T I N

Address (number and street, PO Box, or PMB no.)

Apt. no. /Ste. no.

City

State

Part I

Check this box if this
is an amended form

•

ZIP code

Additional Tax on Early Distributions – Complete this part if you received a taxable distribution, before you reached age 59½, from a qualified
retirement plan (including an IRA) or modified endowment contract. You may also have to complete this part if you received a federal Form 1099-R
that incorrectly indicates an early distribution or you received a Roth IRA distribution (see instructions).

1 Early distributions included in income. For Roth IRA distributions, see instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
00
2 Early distributions included on line 1 that are not subject to additional tax. See instructions. Enter the appropriate exception
.................................................................
2
00
number from instructions
3 Amount subject to additional tax. Subtract line 2 from line 1*. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
00
4 Tax due. Multiply line 3 by 2½% (.025). Enter the amount here and include this amount in the total on Form 540, line 63 or
Form 540NR, line 73. If you are not required to file a California income tax return, sign this form below and refer to
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00
the instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
*If any part of the amount on line 3 was a distribution from a SIMPLE IRA, you may have to include 6% (.06) of that amount on line 4 instead of 2½% (.025).
See instructions.
Part II Additional Tax on Certain Distributions from Education Accounts and ABLE Accounts – Complete this part if you included an amount in income on
Schedule CA (540 or 540NR) from a Coverdell education savings account (ESA), a qualified tuition program (QTP), or an ABLE account.
5
6
7
8

Distributions included in income from a Coverdell ESA, a QTP, or an ABLE account. See instructions . . . . . . . . . . . . . . . . . .
Distributions included on line 5 that are not subject to additional tax. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amount subject to additional tax. Subtract line 6 from line 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax due. Multiply line 7 by 2½% (.025). Enter the amount here and include this amount in the total on Form 540, line 63 or
Form 540NR, line 73. If you are not required to file a California income tax return, sign this form below and refer to
the instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5
6
7

00
00
00

8

00

Part III Additional Tax on Distributions from Archer and Medicare Advantage Medical Savings Accounts (MSAs) – Complete this part if you reported a
taxable distribution from an MSA on federal Form 8853.
9 Taxable Archer MSA distribution from federal Form 8853, line 8. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
10 a If you meet any of the exceptions to the 12.5% tax (see instructions), check here. . . . . . . . . . . . . . . . . . . . .
10a •
b Otherwise, multiply line 9 by 12.5% (.125). Enter the amount here and include this amount in the total on
Form 540, line 63 or Form 540NR, line 73. If you are not required to file a California income
tax return, sign this form below and refer to the instructions . . . . . . . . . . . . . . . . . . . . .
10b
00
11 Additional tax due from Medicare Advantage MSA distributions. Enter the amount from federal Form 8853, line 13b. Also,
include this amount in the total on Form 540, line 63 or Form 540NR, line 73. If you are not required to file a California
income tax return, sign this form below and refer to the instructions. Form 540NR filers, see instructions . . . . . . . . . . . . . . 11
Signature. Complete only if you are filing this form by itself and not with your tax return.
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and
belief, it is true, correct, and complete. It is unlawful to forge a spouse’s/registered domestic partner’s signature.
Your signature

Date

X

Signature of paid preparer (declaration of preparer is based on all information of which preparer has any knowledge.)

PTIN

Firm’s name (or yours if self-employed) and address

Firm's FEIN

For Privacy Notice, get FTB 1131 EN-SP.

7511233

FTB 3805P 2023

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