2022 Income Tax Return

California Return

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 TAXABLE YEAR FORM

2022 California Resident Income Tax Return 540

APE ATTACH FEDERAL RETURN

626-88-8862 RODR 22 PBA 561720

CLAUDIA A RODRIGUEZ A
R
RP
1712 RUBY LN
MODESTO CA 95350

04-08-1996

Enter your county at time of filing (see instructions)

STANISLAUS
Principal Residence

If your address above is the same as your principal/physical residence address at the time of filing, check this box . . . X
If not, enter below your principal/physical residence address at the time of filing.
Street address (number and street) (If foreign address, see instructions.) Apt. no/ste. no.

City State ZIP code

If your California filing status is different from your federal filing status, check the box here . . . . . . . . . . . . . .

1 Single 4 X Head of household (with qualifying person). See instructions.

Filing Status

2 Married/RDP filing jointly. See instr. 5 Qualifying surviving spouse/RDP. Enter year spouse/RDP died.

See instructions.

3 Married/RDP filing separately. Enter spouse’s/RDP’s SSN or ITIN above and full name here.

6 If someone can claim you (or your spouse/RDP) as a dependent, check the box here. See instr. . . . . . . ● 6

▶ For line 7, line 8, line 9, and line 10: Multiply the number you enter in the box by the pre-printed dollar amount for that line.
Whole dollars only
7 Personal: If you checked box 1, 3, or 4 above, enter 1 in the box. If you checked
Exemptions

box 2 or 5, enter 2 in the box. If you checked the box on line 6, see instructions. 7 1 X $140 = ● $ 140
8 Blind: If you (or your spouse/RDP) are visually impaired, enter 1;
if both are visually impaired, enter 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 X $140 = $
9 Senior: If you (or your spouse/RDP) are 65 or older, enter 1;
if both are 65 or older, enter 2. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . ●9 X $140 = $

 3101224 Form 540 2022 Side 1

Your name: CLAUDIA A RODRIGU Your SSN or ITIN: 626888862
10 Dependents: Do not include yourself or your spouse/RDP.
Dependent 1 Dependent 2 Dependent 3
First Name NATALIA IVE
Last Name RODRIGUEZ
Exemptions

SSN. See
instructions. ● 111513320 ● ●
Dependent’s
relationship DAUGHTER
to you

Total dependent exemptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 10 1 X $433 = $ 433

11 Exemption amount: Add line 7 through line 10. Transfer this amount to line 32 . . . . . . . . . . . . . 11 $ 573

12 State wages from your federal

Form(s) W-2, box 16 . . . . . . . . . . . . . . . . . . . . . . ● 12
0 . 00

13 Enter federal adjusted gross income from federal Form 1040 or 1040-SR, line 11 . . . . . . . . 13
11475 . 00
14 California adjustments – subtractions. Enter the amount from Schedule CA (540),
Part I, line 27, column B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 14 . 00
15 Subtract line 14 from line 13. If less than zero, enter the result in parentheses.
11475 . 00
Taxable Income

See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
16 California adjustments – additions. Enter the amount from Schedule CA (540),
Part I, line 27, column C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 16 . 00

17 California adjusted gross income. Combine line 15 and line 16 . . . . . . . . . . . . . . . . . . . . . . . ● 17 11475 . 00

{ {
18 Enter the Your California itemized deductions from Schedule CA (540), Part II, line 30; OR
larger of Your California standard deduction shown below for your filing status:
• Single or Married/RDP filing separately. . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5,202
• Married/RDP filing jointly, Head of household, or Qualifying surviving spouse/RDP. $10,404
If Married/RDP filing separately or the box on line 6 is checked, STOP. See instructions ● 18
10404 . 00
19 Subtract line 18 from line 17. This is your taxable income.
If less than zero, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
1071 . 00

X Tax Table Tax Rate Schedule

31 Tax. Check the box if from:
● FTB 3800 ● FTB 3803 . . . . . . . . . . . . . . . . ● 31 11 . 00
32 Exemption credits. Enter the amount from line 11. If your federal AGI is more than
$229,908, see instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
573 . 00
Tax

33 Subtract line 32 from line 31. If less than zero, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 0 . 00

34 Tax. See instructions. Check the box if from: ● Schedule G-1 ● FTB 5870A . . ● 34 . 00

35 Add line 33 and line 34 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 0 . 00

●
Special Credits

40 Nonrefundable Child and Dependent Care Expenses Credit. See instructions. . . . . . . . . . . . . 40

525 . 00

43 Enter credit name code ● and amount. . . ● 43 . 00

44 Enter credit name code ● and amount. . . ● 44 . 00

Side 2 Form 540 2022  3102224

 Your name:
CLAUDIA A RODRIGU Your SSN or ITIN: 626888862

45 To claim more than two credits. See instructions. Attach Schedule P (540). . . . . . . . . . . . . . ● 45 . 00
Special Credits

46 Nonrefundable Renter’s Credit. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 46

120 . 00

47 Add line 40 through line 46. These are your total credits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 645 . 00

48 Subtract line 47 from line 35. If less than zero, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 0 . 00

61 Alternative Minimum Tax. Attach Schedule P (540) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 61 . 00

Other Taxes

62 Mental Health Services Tax. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 62 . 00

63 Other taxes and credit recapture. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 63 . 00

64 Add line 48, line 61, line 62, and line 63. This is your total tax. . . . . . . . . . . . . . . . . . . . . . . . ● 64 0 . 00

71 California income tax withheld. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 71 . 00

72 2022 California estimated tax and other payments. See instructions . . . . . . . . . . . . . . . . . . . ● 72 . 00

73 Withholding (Form 592-B and/or Form 593). See instructions. . . . . . . . . . . . . . . . . . . . . . . . ● 73 . 00

Payments

74 Excess SDI (or VPDI) withheld. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 74 . 00

75 Earned Income Tax Credit (EITC). See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 75 557 . 00

76 Young Child Tax Credit (YCTC). See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 76

1083 . 00

77 Foster Youth Tax Credit (FYTC). See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 77 . 00

78 Add line 71 through line 77. These are your total payments.
See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
1640 . 00

●
Use Tax

91 Use Tax. Do not leave blank. See instructions . . . . . . . . . . . . . . . . . . . . . . 91 . 00

If line 91 is zero, check if: X No use tax is owed. You paid your use tax obligation directly to CDTFA.

92 If you and your household had full-year health care coverage, check the box.
● X
Penalty

See instructions. Medicare Part A or C coverage is qualifying health care coverage. . . . . . . .

ISR

If you did not check the box, see instructions.

Individual Shared Responsibility (ISR) Penalty. See instructions . . . . . . . . ● 92 . 00

93 Payments balance. If line 78 is more than line 91, subtract line 91 from line 78 . . . . . . . . . . 93 1640 . 00
Overpaid Tax/Tax Due

94 Use Tax balance. If line 91 is more than line 78, subtract line 78 from line 91 . . . . . . . . . . . 94 . 00
95 Payments after Individual Shared Responsibility Penalty. If line 93 is more than line 92,
subtract line 92 from line 93. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 1640 . 00
96 Individual Shared Responsibility Penalty Balance. If line 92 is more than line 93,
subtract line 93 from line 92. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 . 00

97 Overpaid tax. If line 95 is more than line 64, subtract line 64 from line 95. . . . . . . . . . . . . . . 97 1640 . 00

 3103224 Form 540 2022 Side 3

Your name:
CLAUDIA A RODRIGU Your SSN or ITIN: 626888862

98 Amount of line 97 you want applied to your 2023 estimated tax . . . . . . . . . . . . . . . . . . . . . . ● 98 . 00

Tax/Tax Due
Overpaid

99 Overpaid tax available this year. Subtract line 98 from line 97 . . . . . . . . . . . . . . . . . . . . . . . . ● 99

1640 . 00

100 Tax due. If line 95 is less than line 64, subtract line 95 from line 64 . . . . . . . . . . . . . . . . . . . 100 0 . 00
Code Amount

California Seniors Special Fund. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 400 . 00

Alzheimer’s Disease and Related Dementia Voluntary Tax Contribution Fund . . . . . . . . . . . . . ● 401 . 00

Rare and Endangered Species Preservation Voluntary Tax Contribution Program . . . . . . . . . ● 403 . 00

California Breast Cancer Research Voluntary Tax Contribution Fund. . . . . . . . . . . . . . . . . . . . ● 405 . 00

California Firefighters’ Memorial Voluntary Tax Contribution Fund . . . . . . . . . . . . . . . . . . . . . ● 406 . 00

Emergency Food for Families Voluntary Tax Contribution Fund . . . . . . . . . . . . . . . . . . . . . . . ● 407 . 00

California Peace Officer Memorial Foundation Voluntary Tax Contribution Fund. . . . . . . . . . . ● 408 . 00

California Sea Otter Voluntary Tax Contribution Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 410 . 00

California Cancer Research Voluntary Tax Contribution Fund . . . . . . . . . . . . . . . . . . . . . . . . . ● 413 . 00

Contributions

School Supplies for Homeless Children Voluntary Tax Contribution Fund . . . . . . . . . . . . . . . ● 422 . 00

State Parks Protection Fund/Parks Pass Purchase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 423 . 00

Protect Our Coast and Oceans Voluntary Tax Contribution Fund. . . . . . . . . . . . . . . . . . . . . . . ● 424 . 00

Keep Arts in Schools Voluntary Tax Contribution Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 425 . 00

Prevention of Animal Homelessness and Cruelty Voluntary Tax Contribution Fund . . . . . . . . ● 431 . 00

California Senior Citizen Advocacy Voluntary Tax Contribution Fund . . . . . . . . . . . . . . . . . . . ● 438 . 00

Native California Wildlife Rehabilitation Voluntary Tax Contribution Fund. . . . . . . . . . . . . . . . ● 439 . 00

Rape Kit Backlog Voluntary Tax Contribution Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 440 . 00

Suicide Prevention Voluntary Tax Contribution Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 444 . 00

Mental Health Crisis Prevention Voluntary Tax Contribution Fund. . . . . . . . . . . . . . . . . . . . . . ● 445 . 00

California Community and Neighborhood Tree Voluntary Tax Contribution Fund . . . . . . . . . . ● 446 . 00

110 Add amounts in code 400 through code 446. This is your total contribution . . . . . . . . . . . . . ● 110
0 . 00
You Owe
Amount

111 AMOUNT YOU OWE. If you do not have an amount on line 99, add line 94, line 96, line 100, and line 110. See instructions. Do not send cash.
Mail to: FRANCHISE TAX BOARD, PO BOX 942867, SACRAMENTO CA 94267-0001. . . . . ● 111 . 00
Pay Online – Go to ftb.ca.gov/pay for more information.

Side 4 Form 540 2022  3104224

Your name:
CLAUDIA A RODRIGU Your SSN or ITIN: 626888862

112 Interest, late return penalties, and late payment penalties . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 . 00
Interest and
Penalties

113 Underpayment of estimated tax.

Check the box: ● FTB 5805 attached ● FTB 5805F attached . . . . . . . . . . . ● 113 . 00

114 Total amount due. See instructions. Enclose, but do not staple, any payment . . . . . . . . . . . . 114 . 00
115 REFUND OR NO AMOUNT DUE. Subtract the sum of line 110, line 112, and line 113 from line 99. See instructions.

Mail to: FRANCHISE TAX BOARD, PO BOX 942840, SACRAMENTO CA 94240-0001. . . . . . . ● 115 1640 . 00

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.
Refund and Direct Deposit

See instructions. 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:
● Type
● Routing number X Checking ● Account number ● 116 Direct deposit amount
044111191 5117236028486 1640 . 00
Savings

The remaining amount of my refund (line 115) is authorized for direct deposit into the account shown below:
● Type
● Routing number Checking ● Account number ● 117 Direct deposit amount

. 00
Savings
Voter
Info.

For voter registration information, check the box and go to sos.ca.gov/elections. See instructions . . . . . . . . . . . . . . . .
IMPORTANT: See the instructions to find out if you should attach a copy of your complete federal tax return.
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 tax return, including accompanying schedules and statements, and to the best of my knowledge and belief, it
is true, correct, and complete.
Your signature Date Spouse’s/RDP’s signature (if a joint tax return, both must sign)

Your email address. Enter only one email address. Preferred phone number

cr9342969@gmail.com 209-261-1151
Sign
Paid preparer’s signature (declaration of preparer is based on all information of which preparer has any knowledge)
Here SELF-PREPARED
It is unlawful
to forge a
spouse’s/
Firm’s name (or yours, if self-employed) ● PTIN
RDP’s
signature.
Firm’s address ● Firm’s FEIN
Joint tax
return?
See
instructions.
Do you want to allow another person to discuss this tax return with us? See instructions . . . . . . . ● Yes X No
Print Third Party Designee’s Name Telephone Number

 3105224 Form 540 2022 Side 5

 TAXABLE YEAR CALIFORNIA SCHEDULE
Alternative Minimum Tax and
2022 Credit Limitations — Residents P (540)
Attach this schedule to Form 540.
Name(s) as shown on Form 540 Your SSN or I T I N
CLAUDIA A RODRIGUEZ 626-88-8862
Part I Alternative Minimum Taxable Income (AMTI) Important: See instructions for information regarding California/federal differences.
1 If you itemized deductions, go to line 2. If you did not itemize deductions, enter your standard
deduction from Form 540, line 18, and go to line 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 10,404 00
2 Medical and dental expenses. Enter the smaller of federal Schedule A (Form 1040), line 4, or 2½% (.025)
of federal Form 1040 or 1040-SR, line 11. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 00
3 Personal property taxes and real property taxes. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 00
4 Certain interest on a home mortgage not used to buy, build, or improve your home. See instructions . . . . . . . . . . . . . . . . . 4 00
5 Miscellaneous itemized deductions. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 00
6 Refund of personal property taxes and real property taxes. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 ( 00 )
Do not include your state income tax refund on this line.
7 Investment interest expense adjustment. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 00
8 Post-1986 depreciation. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 00
9 Adjusted gain or loss. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 00
10 Incentive stock options (ISOs) and California qualified stock options (CQSOs). See instructions . . . . . . . . . . . . . . . . . . . . . 10 00
11 Passive activities adjustment. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 00
12 Beneficiaries of estates and trusts. Enter the amount from Schedule K-1 (541), line 12a . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 00
13 Other adjustments and preferences. Enter the amount, if any, for each item, a through I. See instructions.
a Circulation expenditures . . | 00 g Mining costs . . . . . . . . . . . . . | 00
b Depletion . . . . . . . . . . . . . . | 00 h Patron’s adjustment. . . . . . . . | 00
c Installment sales . . . . . . . . | 00 i Pollution control facilities . . . | 00
d Intangible drilling costs . . . | 00 j Research and experimental . . | 00
e Long-term contracts . . . . . | 00 k Tax shelter farm activities . . . | 00
f Loss limitations . . . . . . . . . | 00 l Related adjustments . . . . . . . | 00

Add amounts on line a through line I, and enter total here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 00

14 Total Adjustments and Preferences. Combine line 1 through line 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 10,404 00
15 Enter taxable income from Form 540, line 19. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1,071 00
16 Net operating loss (NOL) deductions from Schedule CA (540), Part I, Section B, line 9b1, line 9b2, and line 9b3, column B.
Enter as a positive amount. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 00
17 AMTI exclusion. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 ( 12,348 00 )
18 If your federal adjusted gross income (AGI) is less than the amount for your filing status (listed below), skip this line and go
to line 19. If you itemized deductions and your federal AGI is more than the amount for your filing status, see instructions.. . . 18 ( 00 )
Single or married/RDP filing separately . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $229,908
Married/RDP filing jointly or qualifying surviving spouse/RDP . . . . . . . . . . . . . . . . . . . . $459,821
Head of household . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $344,867
19 Combine line 14 through line 18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 -873 00
20 Alternative minimum tax NOL deduction. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 00
21 Alternative Minimum Taxable Income. Subtract line 20 from line 19 (if married/RDP filing separately and line 21
is more than $436,827, see instructions). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 -873 00
Part II Alternative Minimum Tax (AMT)
22 Exemption Amount. (If this schedule is for a certain child under age 24, see instructions.)
If your filing status is: And line 21 is not over: Enter on line 22:

}
Single or head of household $317,062 $84,550
Married/RDP filing jointly or qualifying surviving spouse/RDP $422,750 $112,734 22 84,550 00
Married/RDP filing separately $211,371 $56,364
If Part I, line 21 is more than the amount shown above for your filing status, see instructions.
23 Subtract line 22 from line 21. If zero or less, enter -0-. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 00
24 Tentative Minimum Tax. Multiply line 23 by 7.0% (.07) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 00
25 Regular tax before credits from Form 540, line 31. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 11 00
26 Alternative Minimum Tax. Subtract line 25 from line 24. If zero or less, enter -0- here and on Form 540, line 61. If more
than zero, enter here and on Form 540, line 61. If you make estimated tax payments for taxable year 2023, enter amount from
line 26 on the 2023 Form 540-ES, California Estimated Tax Worksheet, line 16. (Exception: If you have carryover credit for solar
energy or commercial solar energy, first enter the result on Side 2, Part III, Section C, line 23 or 24) . . . . . . . . . . . . . . . . . 26 0 00

For Privacy Notice, get FTB 1131 EN-SP.  7971224 Schedule P (540) 2022 Side 1
Part III Credits that Reduce Tax Note: Be sure to attach your credit forms to Form 540.
1 Enter the amount from Form 540, line 35. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 00
1 _____________________
2 Enter the tentative minimum tax from Side 1, Part II, line 24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 00
2 _____________________
(a) (b) (c) (d)
Credit Credit used Tax balance that Credit
amount this year may be offset carryover
Section A – Credits that reduce excess tax. by credits

3 Subtract line 2 from line 1. If zero or less enter -0- and see instructions.
This is your excess tax which may be offset by credits . . . . . . . . . . . . . . . . . . . . . . 3 0
A1 Credits that reduce excess tax and have no carryover provisions.
4 Code: 162 Prison inmate labor credit (FTB 3507) . . . . . . . . . . . . . . . . . . . . . . . . . . 4 0 0 0
5 Code: 232 Child and dependent care expenses credit (FTB 3506) . . . . . . . . . . . . . . 5 525 0 0
A2 Credits that reduce excess tax and have carryover provisions. See instructions.
6 Code: ____ ____ ____ Credit Name: 6
7 Code: ____ ____ ____ Credit Name: 7
8 Code: ____ ____ ____ Credit Name: 8
9 Code: ____ ____ ____ Credit Name: 9
10 Code: 188 Credit for prior year alternative minimum tax . . . . . . . . . . . . . . . . . . . . . 10
Section B – Credits that may reduce tax below tentative minimum tax.
11 If Part III, line 3 is zero, enter the amount from line 1. If line 3 is more than
zero, enter the total of line 2 and the last entry in column (c). . . . . . . . . . . . . . . . . 11 0
B1 Credits that reduce net tax and have no carryover provisions.
12 Code: 170 Credit for joint custody head of household . . . . . . . . . . . . . . . . . . . . . . . 12 0 0 0
13 Code: 173 Credit for dependent parent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 0 0 0
14 Code: 163 Credit for senior head of household . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 0 0 0
15 Nonrefundable renter’s credit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 120 0 0
B2 Credits that reduce net tax and have carryover provisions. See instructions.
16 Code: ____ ____ ____ Credit Name: 16
17 Code: ____ ____ ____ Credit Name: 17
18 Code: ____ ____ ____ Credit Name: 18
19 Code: ____ ____ ____ Credit Name: 19
B3 Other state tax credit.
20 Code: 187 Other state tax credit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 0 0 0
B4 Pass-through entity elective tax credit. See instructions.
21 Code: 242 Pass-through entity elective tax credit . . . . . . . . . . . . . . . . . . . . . . . . . . 21 0 0 0 0
Section C – Credits that may reduce alternative minimum tax.
22 Enter your alternative minimum tax from Side 1, Part II, line 26 . . . . . . . . . . . . . . . 22
23 Code: 180 Solar energy credit carryover from Section B2, column (d) . . . . . . . . . . 23
24 Code: 181 Commercial solar energy credit carryover from Section B2, column (d). . 24
25 Adjusted AMT. Enter the balance from line 24, column (c) here
and on Form 540, line 61 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Side 2 Schedule P (540) 2022  7972224

 TAXABLE YEAR FORM

2022 California Earned Income Tax Credit 3514

Attach to your California Form 540, Form 540 2EZ, or Form 540NR.
Name(s) as shown on tax return Your SSN or ITIN

CLAUDIA A RODRIGUEZ 626-88-8862

If you are separated from your spouse/registered domestic partner (RDP), filing a separate return, and meet the requirements to claim
the California Earned Income Tax Credit (EITC) (see instructions), check here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Before you begin:
If you claim the California EITC even though you know you are not eligible, you may not be allowed to take the credit for up to 10 years.
If you are claiming the California EITC, you must provide your date of birth (DOB), and spouse’s/RDP's DOB if filing jointly, on your California tax return.
If you qualify for the California EITC, you may also qualify for the Young Child Tax Credit (YCTC) and/or the Foster Youth Tax Credit (FYTC). You
may also qualify for the YCTC if you would otherwise have been allowed the California EITC but you have earned income of zero dollars or less. See
instructions for additional information.
Follow Step 1 through Step 11 in the instructions to determine if you meet the requirements to complete this form, and to figure the amount of the credit(s).
Part I Qualifying Information See Specific Instructions.

1 a Has the Internal Revenue Service (IRS) previously disallowed your federal Earned Income Credit (EIC)? . . Yes X No

b Has the Franchise Tax Board (FTB) previously disallowed your California EITC?. . . . . . . . . . . . . . . . . . . . . . Yes X No

2 Federal AGI (federal Form 1040 or 1040-SR, line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 2 11475 . 00

3 Federal EIC (federal Form 1040 or 1040-SR, line 27) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 3 3733 . 00

Part II Investment Income Information

4 Investment Income. See instructions for Step 2 – Investment Income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 4 . 00

Part III Qualifying Child Information
You must complete Part I and Part II before filling out Part III. If you are not claiming a qualifying child, skip Part III and go to Step 4 in the instructions.
Qualifying Child Information (Complete line 5 through line 12 for each child under Child 1, Child 2, or Child 3, as applicable.)
Child 1 Child 2 Child 3

5 First name . . . . . . NATALIA IVE

6 Last name . . . . . . RODRIGUEZ
7 SSN or ITIN.
See instructions. ● 111513320 ● ●
8 Date of birth (mm/dd/yyyy). If born after 2003 and the child is younger than you (or your spouse/RDP, if filing jointly),
skip line 9a and line 9b; go to line 10.

06132017
9 a Was the child under age 24 at the end of 2022, a student, and younger than you (or your spouse/RDP, if filing jointly)?
If yes, go to line 10. If no, go to line 9b. See instructions.

Yes No Yes No Yes No

b Was the child permanently and totally disabled during any part of 2022? If yes, go to line 10. If no, stop here.
The child is not a qualifying child.

Yes No Yes No Yes No

10 Child’s relationship to you. See instructions.

DAUGHTER
11 Number of days child lived with you in California during 2022. Do not enter more than 365 days. See instructions.

365

For Privacy Notice, get FTB 1131 EN-SP.  8461224 FTB 3514 2022 Side 1
12 Child’s physical address during 2022. See instructions.
a Street address (number, street, and apt. no./ste. no.)

Child 1 1712 RUBY LN

b City c State d ZIP code

MODESTO CA 95350
a Street address (number, street, and apt. no./ste. no.)

Child 2
b City c State d ZIP code

a Street address (number, street, and apt. no./ste. no.)

Child 3
b City c State d ZIP code

Part IV California Earned Income

13 Wages, salaries, tips, and other employee compensation, subject to California withholding. See instructions. . ● 13 . 00
14 IHSS payments. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 . 00
15 Prison inmate wages and/or pension or annuity from a nonqualified deferred compensation plan or a
nongovernmental IRC Section 457 plan. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 . 00
16 Subtract line 14 and line 15 from line 13. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 16 . 00
17 Nontaxable combat pay. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 . 00
18 Business income or (loss). Enter amount from Worksheet 3, line 5. See instructions. . . . . . . . . . . . . . . . . . . 18 11475 . 00

a Business name . . . . . . . . . . . . . . . HOUSE CLEANING

Street address (number, street, and apt. no./ste. no.).

b Business address . . . . . . . . . . . . . 1712 RUBY LN

City State ZIP code

MODESTO CA 95350

c Business license number . . . . . . .

d SEIN . . . . . . . . . . . . . . . . . . . . . . .

e Business code . . . . . . . . . . . . . . . 561720

19 California Earned Income. Add line 16, line 17, and line 18. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 19 11475 . 00
Part V California Earned Income Tax Credit (Complete Step 6 in the instructions.)

20 California EITC. Enter amount from California Earned Income Tax Credit Worksheet, Part III, line 6.
This amount should also be entered on Form 540, line 75; or Form 540 2EZ, line 23a . . . . . . . . . . . . . . . . . . ● 20 557 . 00

Side 2 FTB 3514 2022  8462224

Part VI Nonresident or Part-Year Resident California Earned Income Tax Credit

21 CA Exemption Credit Percentage from Form 540NR, line 38. See instructions. . . . 21
22 Nonresident or Part-Year Resident EITC. Multiply line 20 by line 21.
This amount should also be entered on Form 540NR, line 85 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 22 . 00
Part VII Young Child Tax Credit (See Step 8 in the instructions before completing this part.)

23 California Earned Income. Enter the amount from form FTB 3514, line 19. If the amount entered here
is greater than $0, do not complete line 23a or line 23b and continue on to line 24. . . . . . . . . . . . . . . . . . . . 23 11475 . 00

a Total wages, salaries, tips, and other employee compensation. See instructions . . ● 23a . 00
b If your total federal net loss exceeds $32,490, check the box. See instructions . . . ●

24 Available Young Child Tax Credit.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 1083 . 00

• If the amount on line 23 is $25,000 or less, skip line 25 through line 27 and enter $1,083 on line 28.
If applicable, complete line 29 and line 30.
• If the amount on line 23 is greater than $25,000, complete line 25 through line 28. If applicable,
complete line 29 and line 30.

25 Excess Earned Income over threshold. Subtract $25,000 from line 23 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 25

. 00
26 Divide line 25 by 100. Enter the result as a decimal out to two decimal places, do not round. . . . . . . . . . . . . 26
27 Reduction amount. Multiply line 26 by $21.66. Enter the result as a decimal out to two decimal places,
do not round. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 27

28 Young Child Tax Credit.

• If you did not need to complete line 25 through line 27, your credit is the $1,083 from line 24.
• If you completed lines 25 through 27, to compute your credit, subtract line 27 from line 24. If your credit
amount is between $0 and $1, enter $1. If your credit amount is over $1, round to the nearest whole dollar.
This amount should also be entered on Form 540, line 76; or Form 540 2EZ, line 23b . . . . . . . . . . . . . . . . . . ● 28 1083 . 00
Part VIII Nonresident or Part-Year Resident Young Child Tax Credit (See Step 9 in the instructions.)

29 CA Exemption Credit Percentage from Form 540NR, line 38. See instructions . . . . 29
30 Nonresident or Part-Year Resident YCTC. Multiply line 28 by line 29.
This amount should also be entered on Form 540NR, line 86 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 30 . 00
Part IX Foster Youth Tax Credit (See Step 10 in the instructions.)

31 Who is claiming the FYTC? If both spouses/RDPs qualify, you must each check the box that applies to you. See instructions.

a Primary Taxpayer: My name is the first name listed on this return. . . . . . . . . . . . . . . . ●

b Spouse/RDP: My name is listed as the spouse/RDP on this joint return. . . . . . . . . . . ●

32 Qualifying foster youth information. See instructions. Primary Taxpayer Spouse/RDP

a First name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● ●

b Last name. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● ●

 8463224 FTB 3514 2022 Side 3

33 To better assist us in verifying your eligibility, please check the applicable box(es) below. See instructions.
a Primary Taxpayer: By checking the box and signing the tax return to which this
form is attached, I certify that I am the primary taxpayer listed on this return and
voluntarily consent and authorize the California Department of Social Services
and any of its affiliated programs (including, but not limited to, CalWORKS and
CalFRESH) to confirm or deny, and disclose relevant information to the State of
California Franchise Tax Board regarding, my eligibility for the FYTC . . . . . . . . . . . . . ●

b Spouse/RDP: By checking the box and signing the tax return to which this form is
attached, I certify that I am the spouse/RDP listed on this joint return and voluntarily
consent and authorize the California Department of Social Services and any of
its affiliated programs (including, but not limited to, CalWORKS and CalFRESH)
to confirm or deny, and disclose relevant information to the State of California
Franchise Tax Board regarding, my eligibility for the FYTC. . . . . . . . . . . . . . . . . . . . . ●

Note: Each individual who claims the FYTC and does not check the applicable box above must attach
to this return a letter issued by a county or state agency confirming that individual’s status as a
foster youth at or after age 13, or other proof of status, as a condition of receiving the FYTC.

34 California Earned Income. Enter the amount from form FTB 3514, line 19 . . . . . . . . . . . . . . . . . . . . . . . . . . 34 . 00
35 Available Foster Youth Tax Credit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 35 . 00
• If the amount on line 34 is $25,000 or less, skip line 36 through line 38 and enter on line 35 and line 39
the following amount.
○ If either the taxpayer or spouse/RDP is claiming the FYTC, enter $1,083 on line 35 and line 39.
○ If both taxpayer and spouse/RDP are claiming the FYTC, enter $2,166 on line 35 and line 39.
If applicable, complete line 40 and line 41.
• If the amount on line 34 is greater than $25,000, complete line 36 through line 38 and enter on line 35
the following amount.
○ If either the taxpayer or spouse/RDP is claiming the FYTC, enter $1,083 on line 35.
○ If both taxpayer and spouse/RDP are claiming the FYTC, enter $2,166 on line 35.
If applicable, complete line 40 and line 41.
36 Excess Earned Income over threshold. Subtract $25,000 from line 34. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 36 . 00
37 Divide line 36 by 100. Enter the result as a decimal out to two decimal places, do not round.. . . . . . . . . . . . . 37

38 Reduction amount. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 38
• If either the taxpayer or spouse/RDP is claiming the FYTC, multiply line 37 by $21.66.
Enter the result as a decimal out to two decimal places, do not round.
• If both taxpayer and spouse/RDP are claiming the FYTC, multiply line 37 by $43.32.
Enter the result as a decimal out to two decimal places, do not round.

39 Foster Youth Tax Credit.

• If you did not need to complete line 36 through line 38, and either the taxpayer or spouse/RDP is
claiming the FYTC, the credit is the $1,083 from line 35.
• If you did not need to complete line 36 through line 38, and both taxpayer and spouse/RDP are claiming
the FYTC, the credit is the $2,166 from line 35.
• If you completed line 36 through line 38, to compute your credit, subtract line 38 from line 35. If your credit
amount is between $0 and $1, enter $1. If your credit amount is over $1, round to the nearest whole dollar.
This amount should also be entered on Form 540, line 77; or Form 540 2EZ, line 23c . . . . . . . . . . . . . . . . . . ● 39 . 00
Part X Nonresident or Part-Year Resident Foster Youth Tax Credit (See Step 11 in the instructions.)

40 CA Exemption Credit Percentage from Form 540NR, line 38. See instructions . . . 40
41 Nonresident or Part-Year Resident FYTC. Multiply line line 39 by line 40.
This amount should also be entered on Form 540NR, line 87 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 41 . 00

Side 4 FTB 3514 2022  8464224

 TAXABLE YEAR CALIFORNIA FORM

2022 Child and Dependent Care Expenses Credit 3506

Attach to your California Form 540 or Form 540NR.
Name(s) as shown on tax return SSN or ITIN

CLAUDIA A RODRIGUEZ 626-88-8862

Part I  Unearned Income and Other Funds Received in 2022. See instructions.
Source of Income/Funds Amount Source of Income/Funds Amount

Part II  Persons or Organizations Who Provided the Care in California – You must complete this part. See instructions.
1 Enter the following information for each person or organization that provided care in California. Only care provided in California qualifies for the credit.
If you need more space, attach a separate sheet.
Provider Provider
a. Care provider’s name JESSICA M MONTANEZ
b. Care provider’s address
(number, street, apt. no., city, state, 1731 SEATTLE ST
and ZIP code) MODESTO, CA 95350
c. Care provider’s telephone number 209-495-8051
d. Is provider a person or organization? □
□ Organization
X Person □ Person □ Organization
e. Identification number (SSN, ITIN, or FEIN) 623-07-7694
f. Address where care was provided
(number, street, apt. no., city, state, and 1731 SEATTLE ST
ZIP code). PO Box not acceptable. MODESTO, CA 95358
g. Amount paid for care provided 3,000
Did you receive dependent care benefits?  ▶ ▶ ▶ ▶ ▶ No. Complete Part III below.
Yes. Complete Part IV on Side 2 before you complete Part III.
Part III  Credit for Child and Dependent Care Expenses
2 Information about your qualifying person(s).  See instructions.
(a) (b) (c) (d) (e)
Qualifying person’s name Qualifying person’s Qualifying person’s Percentage of Qualified expenses you
social security number (SSN) date of birth physical custody incurred and paid in 2022 for
(See instructions) (DOB – mm/dd/yyyy) (See instructions) the qualifying person’s
First Last or disability status care in California
DOB:_____________
06/13/2017
NATALIA IVE RODRIGUEZ 111-51-3320 Disabled  □   Yes 100% 3,000
DOB:_____________
Disabled  □   Yes
DOB:_____________
Disabled  □   Yes
3 Add the amounts in column (e) of line 2. Do not enter more than $3,000 for one qualifying person or $6,000 for two
or more qualifying persons. If you completed Side 2, Part IV, enter the amount from line 33. . . . . . . . . . . . . . . . . . . . . . . . . 3 3,000 00
4 Enter YOUR earned income. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 11,475 00
Nonresidents: Enter only your earned income from California sources. If you do not have earned income from California
sources, stop, you do not qualify for the credit. Military servicemembers, see instructions.
Part-year residents: Enter the total of (1) your earned income from California sources received while you were a
nonresident and (2) all earned income received while you were a resident. Military servicemembers, see instructions.
5 If married or an RDP filing a joint return, enter YOUR SPOUSE’S/RDP’s earned income. (If your spouse/RDP was a
student or was disabled, see instructions.) If you are not filing a joint tax return, enter the amount from line 4. . . . . . . . . . . 5 11,475 00
Nonresidents: Enter only your spouse’s/RDP’s earned income from California sources. If your spouse/RDP does not have
earned income from California sources, stop, you do not qualify for the credit. Military servicemembers, see line 4 instructions.
Part-year residents: Enter the total of (1) your spouse’s/RDP’s earned income from California sources received while he
or she was a nonresident and (2) all earned income your spouse/RDP received while he or she was a resident. Military
servicemembers, see line 4 instructions.
6 Enter the smallest of line 3, line 4, or line 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3,000 00
7 Enter the decimal amount shown in the chart of the instructions for line 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 . ___
3 ___
5
8 Multiply line 6 by the decimal amount on line 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1,050 00
9 Enter the decimal amount listed in the chart of the instructions for line 9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 . ___
5 ___
0
10 Multiply the amount on line 8 by the decimal amount on line 9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 525 00
11 Credit for prior year expenses paid in 2022. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 00
12 Add line 10 and line 11. Enter the amount here and on Form 540, line 40; or Form 540NR, line 50. . . . . . . . . . . . . . . . . . . . . . . . . 12 525 00

For Privacy Notice, get FTB 1131 EN-SP. 126 7251224 FTB 3506  2022  Side 1
 TAXABLE YEAR CALIFORNIA FORM

2022 Head of Household Filing Status Schedule 3532

Attach to your California Form 540, Form 540NR, or Form 540 2EZ.
Name(s) as shown on tax return SSN or ITIN

CLAUDIA A RODRIGUEZ 626-88-8862

Part I  Marital Status
1 Check one box below to identify your marital status. See instructions.
a Not legally married/RDP during 2022 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1a X
b Surviving spouse/RDP (my spouse/RDP died before 01/01/2022) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1b

c Marriage/RDP was annulled. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1c

d Received final decree of divorce, legal separation, dissolution, or termination of marriage/RDP by 12/31/2022. . . . . . . . . . . . . . . 1d

e Legally married/RDP and did not live with spouse/RDP during 2022. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1e

f Legally married/RDP and lived with spouse/RDP during 2022. List the beginning and ending dates for each period when you
lived together. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1f
(mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy)

From:  To:  From:  To: 

Part II  Qualifying Person

2 Check one box below to identify the relationship of the person that qualifies you for the head of household filing status. See instructions.

a Son, daughter, stepson, or stepdaughter. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a X

b Grandchild, brother, sister, half brother, half sister, stepbrother, stepsister, nephew, or niece. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2b

c Eligible foster child. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2c

d Father, mother, stepfather, or stepmother . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2d

e Grandfather, grandmother, son-in-law, daughter-in-law, father-in-law, mother-in-law, brother-in-law,

sister-in-law, uncle, or aunt. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2e

Part III  Qualifying Person Information

3 Information about your qualifying person. See instructions.

First Name. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NATALIA IVE

Last Name. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RODRIGUEZ
SSN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111-51-3320
DOB (mm/dd/yyyy) If your qualifying person is age 19 or older in 2022, go to line 3a. If not, go to line 4.. . . . . . . . 06/13/2017
a Was your qualifying person a full time student under age 24 in 2022?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3a  Yes  No
b Was your qualifying person permanently and totally disabled in 2022?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3b  Yes  No

4 Enter qualifying person’s gross income in 2022. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

5 Number of days your qualifying person lived with you during 2022. See instructions. . . . . . . . . . . . . . . . . . . . . . . . 365
When calculating the total number of days your qualifying person lived with you, you may include any days your qualifying person was temporarily
absent from your home. For example, illness, education, business, vacations, military service, and incarceration. In the event of a birth or death of
your qualifying person during the year, enter 365 days. See instructions.

For Privacy Notice, get FTB 1131 EN-SP. 126 8481224 FTB 3532  2022