INCOME TAX SERVICES

VICENTE A. LOBEDERIO JR.

7442 GRIBBLE ST.
SAN DIEGO, CA 92114
(619)274-2150 / (619)274-3925

February 2, 2023

RENATO L and LEONILA S MARMITO

2235 E 12TH ST
NATIONAL CITY, CA 91950

Please find enclosed a copy of your 2021 federal income tax return for your records.
Your federal return was e-filed and accepted by the IRS on March 2, 2022;
therefore, do not mail your federal Form 1040 to the IRS.

The amount you overpaid on your federal return is $7,116. The amount to be
refunded to you by direct deposit is $7,116.

If you have any questions about your tax return, please contact me. Thank you for
letting me be of service to you.

Sincerely,

VICENTE A. LOBEDERIO JR
7442 GRIBBLE ST
SAN DIEGO, CA 92114
(619)274-2150
 INCOME TAX SERVICES
VICENTE A. LOBEDERIO JR.
7442 GRIBBLE ST.
SAN DIEGO, CA 92114
(619)274-2150 / (619)274-3925

February 2, 2023

RENATO L and LEONILA S MARMITO

2235 E 12TH ST
NATIONAL CITY, CA 91950

Please find enclosed a copy of your 2021 California income tax return for your
records. Your California income tax return was electronically filed and accepted by
the FTB on February 25, 2022; therefore, do not mail your California income tax
return to the Franchise Tax Board.

The amount you overpaid on your California income tax return is $643. The amount
of overpayment applied to your 2022 estimates is $0. The amount to be refunded to
you by direct deposit is $643.

If you have any questions about your tax return, please contact me. Thank you for
letting me be of service to you.

Sincerely,

VICENTE A. LOBEDERIO JR
7442 GRIBBLE ST
SAN DIEGO, CA 92114
(619)274-2150
 2021
Income Tax Return

Prepared For:
RENATO L and LEONILA S MARMITO
2235 E 12TH ST
NATIONAL CITY, CA 91950
(619)753-0833

Prepared By:

VICENTE A. LOBEDERIO JR
7442 GRIBBLE ST
SAN DIEGO, CA 92114
Telephone: (619)274-2150
FAX: (619)795-7017
Email: [email protected]
 Department of the Treasury–Internal Revenue Service (99)
1040 2021
Form
U.S. Individual Income Tax Return OMB No. 1545-0074 IRS Use Only – Do not write or staple in this space.

Filing Status Single X Married filing jointly Married filing separately (MFS) Head of household (HOH) Qualifying widow(er) (QW)
Check only If you checked the MFS box, enter the name of your spouse. If you checked the HOH or QW box, enter the child’s name if the qualifying person is
one box.
a child but not your dependent
Your first name and middle initial Last name Your social security number

RENATO L MARMITO 608-79-4506

If joint return, spouse's first name and middle initial Last name Spouse's social security number

LEONILA S MARMITO 729-20-9294

Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Presidential Election Campaign
2235 E 12TH ST Check here if you, or your spouse
City, town, or post office. If you have a foreign address, also complete spaces below. State ZIP code if filing jointly, want $3 to go to this
NATIONAL CITY CA 91950 fund. Checking a box below will
Foreign country name Foreign province/state/county Foreign postal code not change your tax or refund.
You Spouse
At any time during 2021, did you receive, sell, send, exchange, or otherwise acquire any financial interest in any virtual currency? Yes X No
Standard Someone can claim: You as a dependent Your spouse as a dependent
Deduction Spouse itemizes on a separate return or you were a dual-status alien
Age/Blindness You: Were born before January 2, 1957 Are blind Spouse: Was born before January 2, 1957 Is blind
Dependents (see instructions): (2) Social security (3) Relationship (4) Check if qualifies for (see instructions):
number to you
If more (1) First name Last name
than four
dependents,
RYUICHI MARMITO 729-24-7933 Son X
see instructions CRESENCIA MARMITO 556-85-3366 Parent X
and check
here
1 Wages, salaries, tips, etc. Attach Form(s) W-2 1 55,333.
Attach
Sch. B if
2a Tax-exempt interest 2a b Taxable interest 2b 15.
required. 3a Qualified dividends 3a b Ordinary dividends 3b
4a IRA distributions 4a b Taxable amount 4b
5a Pensions and annuities 5a b Taxable amount 5b
Standard
Deduction for - 6a Social security benefits 6a b Taxable amount 6b
7 Capital gain or (loss). Attach Schedule D if required. If not required, check here 7
8 Other income from Schedule 1, line 10 8
9 Add lines 1, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income 9 55,348.
10 Adjustments to income from Schedule 1, line 26 10
11 Subtract line 10 from line 9. This is your adjusted gross income 11 55,348.
12a Standard deduction or itemized deductions (from Schedule A) 12a 25,100.
b Charitable contributions if you take the standard deduction (see instructions) 12b 75.
c Add lines 12a and 12b 12c 25,175.
13 Qualified business income deduction from Form 8995 or Form 8995-A 13
14 Add lines 12c and 13 14 25,175.
15 Taxable income. Subtract line 14 from line 11. If zero or less, enter -0- 15 30,173.

For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2021)
UYA
Form 1040 (2021) RENATO L and LEONILA S MARMITO 608-79-4506 Page 2
16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 16 3,223.
17 Amount from Schedule 2, line 3 17
18 Add lines 16 and 17 18 3,223.
19 Nonrefundable child tax credit or credit for other dependents from Schedule 8812 19 1,000.
20 Amount from Schedule 3, line 8 20
21 Add lines 19 and 20 21 1,000.
22 Subtract line 21 from line 18. If zero or less, enter -0- 22 2,223.
23 Other taxes, including self-employment tax, from Schedule 2, line 21 23
24 Add lines 22 and 23. This is your total tax 24 2,223.
25 Federal income tax withheld from:
a Form(s) W-2 25a 8,029.
b Form(s) 1099 25b
c Other forms (see instructions) 25c
d Add lines 25a through 25c 25d 8,029.
If you have a 26 2021 estimated tax payments and amount applied from 2020 return 26
qualifying child, 27a
attach Sch. EIC.
Earned income credit (EIC) NO 27a
Check here if you were born after January 1, 1998, and before
January 2, 2004, and you satisfy all the other requirements for
taxpayers who are at least age 18, to claim the EIC. See Instructions
b Nontaxable combat pay election 27b
c Prior year (2019) earned income 27c
28 Refundable child tax credit or additional child tax credit from Schedule 8812 28
29 American opportunity credit from Form 8863, line 8 29
30 Recovery rebate credit. See instructions 30
31 Amount from Schedule 3, line 15 31 1,310.
32 Add lines 27a and 28 through 31. These are your total other payments and refundable credits 32 1,310.
33 Add lines 25d, 26, and 32. These are your total payments 33 9,339.
34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid 34 7,116.
Refund 35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here 35a 7,116.
Direct deposit?
b Routing number 256074974 c Type: X Checking Savings
See instructions. d Account number 7056987634
36 Amount of line 34 you want applied to your 2022 estimated tax 36
Amount 37 Amount you owe. Subtract line 33 from line 24. For details on how to pay, see instructions 37 0.
You Owe 38 Estimated tax penalty (see instructions) 38
Third Party Do you want to allow another person to discuss this return with the IRS?
Designee See instructions X Yes. Complete below. No

Designee’s Phone Personal identification

name VICENTE A LOBEDERIO no. 619-274-2150 number (PIN) 42150
Sign Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true,
correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here
Your signature Date Your occupation
Joint return?
See instructions. FISH CLEANER
Keep a copy for Spouse's signature. If a joint return, both must sign. Date Spouse's occupation
your records.
UNEMPLOYED
Phone no. (619)753-0833 Email address
Preparer's name Preparer's signature Date PTIN Check if:
Paid
Preparer VICENTE A LOBEDERIO VICENTE A LOBEDERIO 02/02/2023 P00752775 X
Use Only Firm's name VICENTE A. LOBEDERIO JR Phone no. (619)274-2150
Firm's address 7442 GRIBBLE ST, SAN DIEGO, CA, 92114 Firm's EIN
Go to www.irs.gov/Form1040 for instructions and the latest information. Form 1040 (2021)
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SCHEDULE 3 Additional Credits and Payments OMB No. 1545-0074

(Form 1040)

Department of the Treasury

Attach to Form 1040, 1040-SR, or 1040-NR. 2021
Attachment
Internal Revenue Service Go to www.irs.gov/Form1040 for instructions and the latest information. Sequence No. 03
Name(s) shown on Form 1040, 1040-SR, or 1040-NR Your social security number
RENATO L and LEONILA S MARMITO 608-79-4506
Part I Nonrefundable Credits
1 Foreign tax credit. Attach Form 1116 if required 1
2 Credit for child and dependent care expenses from Form 2441, line 11. Attach Form 2441 2
3 Education credits from Form 8863, line 19 3
4 Retirement savings contributions credit. Attach Form 8880 4
5 Residential energy credits. Attach Form 5695 5
6 Other nonrefundable credits:
a General business credit. Attach Form 3800 6a
b Credit for prior year minimum tax. Attach Form 8801 6b
c Adoption credit. Attach Form 8839 6c
d Credit for the elderly or disabled. Attach Schedule R 6d
e Alternative motor vehicle credit. Attach Form 8910 6e
f Qualified plug-in motor vehicle credit. Attach Form 8936 6f
g Mortgage interest credit. Attach Form 8396 6g
h District of Columbia first-time homebuyer credit. Attach Form 8859 6h
i Qualified electric vehicle credit. Attach Form 8834 6i
j Alternative fuel vehicle refueling property credit. Attach Form 8911 6j
k Credit to holders of tax credit bonds. Attach Form 8912 6k
l Amount on Form 8978, line 14. See instructions 6l
z Other nonrefundable credits. List type and amount
6z
7 Total other nonrefundable credits. Add lines 6a through 6z 7
8 Add lines 1 through 5 and 7. Enter here and on Form 1040, 1040-SR, or 1040-NR,
line 20 8 0.
(continued on page 2)
For Paperwork Reduction Act Notice, see your tax return instructions. Schedule 3 (Form 1040) 2021
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RENATO L and LEONILA S MARMITO 608-79-4506
Schedule 3 (Form 1040) 2021 Page 2
Part II Other Payments and Refundable Credits
9 Net premium tax credit. Attach Form 8962 9 1,310.
10 Amount paid with request for extension to file (see instructions) 10
11 Excess social security and tier 1 RRTA tax withheld 11
12 Credit for federal tax on fuels. Attach Form 4136 12
13 Other payments or refundable credits:
a Form 2439 13a
b Qualified sick and family leave credits from Schedule(s) H and
Form(s) 7202 for leave taken before April 1, 2021 13b
c Health coverage tax credit from Form 8885 13c
d Credit for repayment of amounts included in income from earlier years 13d
e Reserved for future use 13e
f Deferred amount of net 965 tax liability (see instructions) 13f
g Credit for child and dependent care expenses from Form 2441,
line 10. Attach Form 2441 13g
h Qualified sick and family leave credits from Schedule(s) H and
Form(s) 7202 for leave taken after March 31, 2021 13h
z Other payments or refundable credits. List type and amount
13z

14 Total other payments or refundable credits. Add lines 13a through 13z 14
15 Add lines 9 through 12 and 14. Enter here and on Form 1040, 1040-SR, or 1040-NR, line 31 15 1,310.
UYA Schedule 3 (Form 1040) 2021
SCHEDULE 8812 Credits for Qualifying Children . . .1040
.......
OMB No. 1545-0074

(Form 1040)
and Other Dependents ..........
2021
Attach to Form 1040, 1040-SR, or 1040-NR. 8812 Attachment
Department of the Treasury
Go to www.irs.gov/Schedule8812 for instructions and the latest information. Sequence No. 47
Internal Revenue Service (99)
Name(s) shown on return Your social security number
RENATO L and LEONILA S MARMITO 608-79-4506
Part I-A Child Tax Credit and Credit for Other Dependents
1 Enter the amount from line 11 of your Form 1040, 1040-SR, or 1040-NR 1 55,348.
2a Enter income from Puerto Rico that you excluded 2a
b Enter the amounts from lines 45 and 50 of your Form 2555 2b
c Enter the amount from line 15 of your Form 4563 2c
d Add lines 2a through 2c 2d
3 Add lines 1 and 2d 3 55,348.
4a Number of qualifying children under age 18 with the required social security number 4a 0
b Number of children included on line 4a who were under age 6 at the end of 2021 4b 0
c Subtract line 4b from line 4a 4c 0
5 If line 4a is more than zero, enter the amount from the Line 5 Worksheet; otherwise, enter -0- 5
6 Number of other dependents, including any qualifying children who are not under age
18 or who do not have the required social security number 6 2
Caution: Do not include yourself, your spouse, or anyone who is not a U.S. citizen, U.S. national, or U.S. resident
alien. Also, do not include anyone you included on line 4a.
7 Multiply line 6 by $500 7 1,000.
8 Add lines 5 and 7 8 1,000.
9 Enter the amount shown below for your filing status.
• Married filing jointly—$400,000
• All other filing statuses—$200,000 } 9 400,000.
10 Subtract line 9 from line 3.
• If zero or less, enter -0-.
• If more than zero and not a multiple of $1,000, enter the next multiple of $1,000. For
example, if the result is $425, enter $1,000; if the result is $1,025, enter $2,000, etc. } 10
11 Multiply line 10 by 5% (0.05) 11
12 Subtract line 11 from line 8. If zero or less, enter -0- 12 1,000.
13 Check all the boxes that apply to you (or your spouse if married filing jointly).
A Check here if you (or your spouse if married filing jointly) had a principal place of abode in the United
States for more than half of 2021 X
B Check here if you (or your spouse if married filing jointly) were a bona fide resident of Puerto Rico for 2021
Part I-B Filers Who Check a Box on Line 13
Caution: If you did not check a box on line 13, do not complete Part I-B; instead, skip to Part I-C.
14a Enter the smaller of line 7 or line 12 14a 1,000.
b Subtract line 14a from line 12 14b
c If line 14a is zero, enter -0-; otherwise, enter the amount from the Credit Limit Worksheet A 14c 3,223.
d Enter the smaller of line 14a or line 14c 14d 1,000.
e Add lines 14b and 14d 14e 1,000.
f Enter the aggregate amount of advance child tax credit payments you (and your spouse if filing jointly) received
for 2021. See your Letter(s) 6419 for the amounts to include on this line. If you are missing Letter 6419, see the
instructions before entering an amount on this line. If you didn't receive any advance child tax credit payments
for 2021, enter -0- 14f
Caution: If the amount on this line doesn’t match the aggregate amounts reported to you (and your spouse if
filing jointly) on your Letter(s) 6419, the processing of your return will be delayed.
g Subtract line 14f from line 14e. If zero or less, enter -0- on lines 14g through 14i and go to Part III 14g 1,000.
h Enter the smaller of line 14d or line 14g. This is your credit for other dependents. Enter this amount on line
19 of your Form 1040, 1040-SR, or 1040-NR 14h 1,000.
i Subtract line 14h from line 14g. This is your refundable child tax credit. Enter this amount on line 28 of
your Form 1040, 1040-SR, or 1040-NR 14i
For Paperwork Reduction Act Notice, see your tax return instructions. Schedule 8812 (Form 1040) 2021
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Schedule 8812 (Form 1040) 2021 Page 2
Part I-C Filers Who Do Not Check a Box on Line 13
Caution: If you checked a box on line 13, do not complete Part I-C.
15a Enter the amount from the Credit Limit Worksheet A 15a
b Enter the smaller of line 12 or line 15a 15b
Additional child tax credit. Complete Parts II-A through II-C if you meet each of the following items.
1. You are not filing Form 2555.
2. Line 4a is more than zero.
3. Line 12 is more than line 15a.
c If you completed Parts II-A through II-C, enter the amount from line 27; otherwise, enter -0- 15c
d Add lines 15b and 15c 15d
e Enter the aggregate amount of advance child tax credit payments you (and your spouse if filing jointly) received
for 2021. See your Letter(s) 6419 for the amounts to include on this line. If you are missing Letter 6419, see the
instructions before entering an amount on this line. If you didn't receive any advance child tax credit payments
for 2021, enter -0- 15e
Caution: If the amount on this line doesn’t match the aggregate amounts reported to you (and your spouse if
filing jointly) on your Letter(s) 6419, the processing of your return will be delayed.
f Subtract line 15e from line 15d. If zero or less, enter -0- on lines 15f through 15h and go to Part III 15f
g Enter the smaller of line 15b or line 15f. This is your nonrefundable child tax credit and credit for other
dependents. Enter this amount on line 19 of your Form 1040, 1040-SR, or 1040-NR 15g
h Subtract line 15g from line 15f. This is your additional child tax credit. Enter this amount on line 28 of your
Form 1040, 1040-SR, or 1040-NR 15h
Part II-A Additional Child Tax Credit (use only if completing Part I-C)
Caution: If you file Form 2555, do not complete Parts II-A through II-C; you cannot claim the additional child tax credit.
Caution: If you checked a box on line 13, do not complete Parts II-A through II-C; you cannot claim the additional
16a Subtract line 15b from line 12. If zero, skip Parts II-A and II-B and enter -0- on line 27 16a
b Number of qualifying children under 18 with the required social security number: 0 x $1,400.
Enter the result. If zero, skip Parts II-A and II-B and enter -0- on line 27 16b
TIP: The number of children you use for this line is the same as the number of children you used for line 4a.
17 Enter the smaller of line 16a or line 16b 17
18a Earned income (see instructions) 18a
b Nontaxable combat pay (see instructions) 18b
19 Is the amount on line 18a more than $2,500?
No. Leave line 19 blank and enter -0- on line 20.
Yes. Subtract $2,500 from the amount on line 18a. Enter the result 19
20 Multiply the amount on line 19 by 15% (0.15) and enter the result 20
Next. On line 16b, is the amount $4,200 or more?
No. If line 20 is zero, enter -0- on line 15c. Otherwise, skip Part II-B and enter the smaller of line 17 or line
20 on line 27.
Yes. If line 20 is equal to or more than line 17, skip Part II-B and enter the amount from line 17 on line 27.
Otherwise, go to line 21.
Part II-B Certain Filers Who Have Three or More Qualifying Children
21 Withheld social security, Medicare, and Additional Medicare taxes from Form(s) W-2,
boxes 4 and 6. If married filing jointly, include your spouse’s amounts with yours. If
your employer withheld or you paid Additional Medicare Tax or tier 1 RRTA taxes, see
instructions 21
22 Enter the total of the amounts from Schedule 1 (Form 1040), line 15; Schedule 2 (Form
1040), line 5; Schedule 2 (Form 1040), line 6; and Schedule 2 (Form 1040), line 13 22
23 Add lines 21 and 22 23
24 1040 and
1040-SR filers: Enter the total of the amounts from Form 1040 or 1040-SR, line 27a,
and Schedule 3 (Form 1040), line 11.
1040-NR filers: Enter the amount from Schedule 3 (Form 1040), line 11.
} 24
25 Subtract line 24 from line 23. If zero or less, enter -0- 25
26 Enter the larger of line 20 or line 25 26
Next, enter the smaller of line 17 or line 26 on line 27.
Part II-C Additional Child Tax Credit
27 Enter this amount on line 15c 27
UYA Schedule 8812 (Form 1040) 2021
Schedule 8812 (Form 1040) 2021 Page 3
Part III Additional Tax (use only if line 14g or line 15f, whichever applies, is zero)
28a Enter the amount from line 14f or line 15e, whichever applies 28a
b Enter the amount from line 14e or line 15d, whichever applies 28b
29 Excess advance child tax credit payments. Subtract line 28b from line 28a. If zero, stop; you do not owe the
additional tax 29
30 Enter the number of qualifying children taken into account in determining the annual advance amount you
received for 2021. See your Letter 6419 for this number. If you are missing your Letter 6419, you are filing a joint
return, or you received more than one Letter 6419, see the instructions before entering a number on this line 30 0
Caution: If the amount on this line doesn’t match the number of qualifying children reported to you (and your
spouse if filing jointly) on your Letter(s) 6419, the processing of your return will be delayed.
31 Enter the smaller of line 4a or line 30 31 0
32 Subtract line 31 from line 30. If zero, skip to line 40 and enter the amount from line 29; otherwise, continue to line 33 32 0
33 Enter the amount shown below for your filing status.

}
• Married filing jointly or Qualifying widow(er)—$60,000
• Head of household—$50,000
• All other filing statuses—$40,000 33
34 Subtract line 33 from line 3. If zero or less, enter -0- 34
35 Enter the amount from line 33 35
36 Divide line 34 by line 35. Enter the result as a decimal (rounded to at least three places). If the result is 1.000 or
more, enter 1.000 36
37 Multiply line 32 by $2,000 37
38 Multiply line 37 by line 36 38
39 Subtract line 38 from line 37 39
40 Subtract line 39 from line 29. If zero or less, enter -0-. This is your additional tax. If more than zero, enter
this amount on Schedule 2 (Form 1040), line 19 40
UYA Schedule 8812 (Form 1040) 2021
Form 8867
(Rev. December 2021)
Paid Preparer's Due Diligence Checklist OMB No. 1545-0074

Department of the Treasury To be completed by preparer and filed with Form 1040, 1040-SR, 1040-NR, 1040-PR, or 1040-SS. Attachment
Internal Revenue Service Go to www.irs.gov/Form8867 for instructions and the latest information. Sequence No. 70
Taxpayer name(s) shown on return Taxpayer identification number

RENATO L and LEONILA S MARMITO 608-79-4506

Enter preparer's name and PTIN

VICENTE A LOBEDERIO P00752775

Part I Due Diligence Requirements
Please check the appropriate box for the credit(s) and/or HOH filing status claimed on the return and complete the related Parts I–V
for the benefit(s) claimed (check all that apply). EIC X CTC/ACTC/ODC AOTC HOH
1 Did you complete the return based on information for the applicable tax year provided by the taxpayer Yes No N/A
or reasonably obtained by you? (See instructions if relying on prior year earned income.) X
2 If credits are claimed on the return, did you complete the applicable EIC and/or CTC/ACTC/ODC
worksheets found in the Form 1040, 1040-SR, 1040-NR, 1040-PR, 1040-SS, or Schedule 8812 instructions,
and/or the AOTC worksheet found in the Form 8863 instructions, or your own worksheet(s) that provides
the same information, and all related forms and schedules for each credit claimed? X
3 Did you satisfy the knowledge requirement? To meet the knowledge requirement, you must do both of
the following.
Interview the taxpayer, ask questions, and contemporaneously document the taxpayer’s responses to
determine that the taxpayer is eligible to claim the credit(s) and/or HOH filing status.
Review information to determine that the taxpayer is eligible to claim the credit(s) and/or HOH filing
status and to figure the amount(s) of any credit(s) X
4 Did any information provided by the taxpayer or a third party for use in preparing the return, or
information reasonably known to you, appear to be incorrect, incomplete, or inconsistent? (If “Yes,”
answer questions 4a and 4b. If “No,” go to question 5.) X
a Did you make reasonable inquiries to determine the correct, complete, and consistent information?
b Did you contemporaneously document your inquiries? (Documentation should include the questions
you asked, whom you asked, when you asked, the information that was provided, and the impact the
information had on your preparation of the return.) X
5 Did you satisfy the record retention requirement? To meet the record retention requirement, you must
keep a copy of your documentation referenced in question 4b, a copy of this Form 8867, a copy of any
applicable worksheet(s), a record of how, when, and from whom the information used to prepare Form
8867 and any applicable worksheet(s) was obtained, and a copy of any document(s) provided by the
taxpayer that you relied on to determine eligibility for the credit(s) and/or HOH filing status or to
figure the amount(s) of the credit(s) X
List those documents provided by the taxpayer, if any, that you relied on:
BIRTH CERT

6 Did you ask the taxpayer whether he/she could provide documentation to substantiate eligibility for the
credit(s) and/or HOH filing status and the amount(s) of any credit(s) claimed on the return if his/her
return is selected for audit? X
7 Did you ask the taxpayer if any of these credits were disallowed or reduced in a previous year? X
(If credits were disallowed or reduced, go to question 7a; if not, go to question 8.)
a Did you complete the required recertification Form 8862?
8 If the taxpayer is reporting self-employment income, did you ask questions to prepare a complete and
correct Schedule C (Form 1040)? X
For Paperwork Reduction Act Notice, see separate instructions. Form 8867 (Rev. 12-2021)
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Form 8867 (2021) RENATO L and LEONILA S MARMITO 608-79-4506 Page 2
Part II Due Diligence Questions for Returns Claiming EIC (If the return does not claim EIC, go to Part III.)
9 a Have you determined that the taxpayer is eligible to claim the EIC for the number of qualifying Yes No N/A
children claimed, or is eligible to claim the EIC without a qualifying child? If the taxpayer is claiming the EIC
and does not have a qualifying child, go to question 10.)
b Did you ask the taxpayer if the child lived with the taxpayer for over half of the year, even if the taxpayer
has supported the child the entire year?
c Did you explain to the taxpayer the rules about claiming the EIC when a child is the qualifying child of
more than one person (tiebreaker rules)?
Part III Due Diligence Questions for Returns Claiming CTC/ACTC/ODC (If the return does not claim CTC, ACTC, or ODC,
go to Part IV.)
10 Have you determined that each qualifying person for the CTC/ACTC/ODC is the taxpayer’s dependent Yes No N/A
who is a citizen, national, or resident of the United States? X
11 Did you explain to the taxpayer that he/she may not claim the CTC/ACTC if the child has not lived with
the taxpayer for over half of the year, even if the taxpayer has supported the child, unless the child’s
custodial parent has released a claim to exemption for the child? X
12 Did you explain to the taxpayer the rules about claiming the CTC/ACTC/ODC for a child of divorced or
separated parents (or parents who live apart), including any requirement to attach a Form 8332 or similar
statement to the return? X
Part IV Due Diligence Questions for Returns Claiming AOTC (If the return does not claim AOTC, go to Part V.)
13 Did the taxpayer provide substantiation for the credit, such as a Form 1098-T and/or receipts for the qualified Yes No
tuition and related expenses for the claimed AOTC?
Part V Due Diligence Questions for Claiming HOH (If the return does not claim HOH filing status, go to Part VI.)
14 Have you determined that the taxpayer was unmarried or considered unmarried on the last day of the tax year Yes No
and provided more than half of the cost of keeping up a home for the year for a qualifying person?
Part VI Eligibility Certification
You will have complied with all due diligence requirements for claiming the applicable credit(s) and/or HOH filing
status on the return of the taxpayer identified above if you:
A. Interview the taxpayer, ask adequate questions, contemporaneously document the taxpayer’s responses on the return or
in your notes, review adequate information to determine if the taxpayer is eligible to claim the credit(s) and/or HOH filing
status and to figure the amount(s) of the credit(s);
B. Complete this Form 8867 truthfully and accurately and complete the actions described in this checklist for any applicable
credit(s) claimed and HOH filing status, if claimed;
C. Submit Form 8867 in the manner required; and
D. Keep all five of the following records for 3 years from the latest of the dates specified in the Form 8867 instructions under
Document Retention.
1. A copy of this Form 8867.
2. The applicable worksheet(s) or your own worksheet(s) for any credit(s) claimed.
3. Copies of any documents provided by the taxpayer on which you relied to determine the taxpayer’s eligibility for the
credit(s) and/or HOH filing status and to figure the amount(s) of the credit(s).
4. A record of how, when, and from whom the information used to prepare this form and the applicable worksheet(s) was
obtained.
5. A record of any additional information you relied upon, including questions you asked and the taxpayer’s responses, to
determine the taxpayer’s eligibility for the credit(s) and/or, HOH filing status and to figure the amount(s) of the credit(s).
If you have not complied with all due diligence requirements, you may have to pay a penalty for each failure to
comply related to a claim of an applicable credit or HOH filing status (see instructions for more information).
15 Do you certify that all of the answers on this Form 8867 are, to the best of your knowledge, true, correct, and Yes No
complete? X
UYA Form 8867 (Rev. 12-2021)
 OMB No. 1545-0074
Form 8962 Premium Tax Credit (PTC)
Attach to Form 1040, 1040-SR, or 1040-NR. 2021
Department of the Treasury Attachment
Internal Revenue Service Go to www.irs.gov/Form8962 for instructions and the latest information. Sequence No. 73
Name shown on your return Your social security number
RENATO L and LEONILA S MARMITO 608-79-4506
A. If you, or your spouse (if filing a joint return), received, or were approved to receive, unemployment compensation for any week beginning during 2021,
check the box. See instructions
B. You cannot take the PTC if your filing status is married filing separately unless you qualify for an exception. See instructions. If you qualify, check the box
Part I Annual and Monthly Contribution Amount
1 Tax family size. Enter your tax family size. See instructions 1 4
2a Modified AGI. Enter your modified AGI. See instructions 2a 55,348.
b Enter the total of your dependents' modified AGI. See instructions 2b
3 Household income. Add the amounts on lines 2a and 2b. See instructions 3 55,348.
4 Federal poverty line. Enter the federal poverty line amount from Table 1-1, 1-2, or 1-3. See instructions. Check the
appropriate box for the federal poverty table used. a Alaska b Hawaii c X Other 48 states and DC 4 26,200.
5 Household income as a percentage of federal poverty line (see instructions) 5 211 %
6 Reserved for future use
7 Applicable figure. Using your line 5 percentage, locate your "applicable figure" on the table in the instructions 7 0.0244
8a Annual contribution amount. Multiply line 3 b Monthly contribution amount. Divide line 8a by
8a 1,350. 12. Round to nearest whole dollar amount 8b 113.
Part II Premium Tax Credit Claim and Reconciliation of Advance Payment of Premium Tax Credit
9 Are you allocating policy amounts with another taxpayer or do you want to use the alternative calculation for year of marriage? See instructions.
Yes. X No. Continue to line 10.
10
Yes. Continue to line 11. Compute your annual PTC. Then skip lines 12-23 X No. Continue to lines 12-23. Compute
and continue to line 24. your monthly PTC and continue to line 24.

(a) (b) Annual applicable (c) Annual (d) Annual maximum (e) Annual premium (f) Annual advance
Annual SLCSP premium premium assistance payment of PTC
Calculation contribution amount tax credit allowed
(Form(s) 1095-A, (subtract (c) from (b); if (Form(s) 1095-A, line
line 33B) (line 8a) zero or less, enter -0-) (smaller of (a) or (d)) 33C)
11 Annual Totals
(c) Monthly
(a) (b) (d) (e) (f) Monthly advance
Monthly contribution amount
payment of PTC
Calculation (amount from line 8b
(Form(s) 1095-A, lines
or alternative marriage
21-32, column C)
monthly calculation)
12 January 701. 701. 113. 588. 588. 359.
13 February 701. 701. 113. 588. 588. 359.
14 March 1,309. 1,401. 113. 1,288. 1,288. 1,077.
15 April 1,309. 1,401. 113. 1,288. 1,288. 1,077.
16 May 1,309. 1,401. 113. 1,288. 1,288. 1,077.
17 June 1,309. 1,401. 113. 1,288. 1,288. 1,077.
18 July
19 August
20 September 1,309. 1,433. 113. 1,320. 1,309. 1,307.
21 October 1,309. 1,433. 113. 1,320. 1,309. 1,307.
22 November 1,309. 1,433. 113. 1,320. 1,309. 1,307.
23 December 1,309. 1,433. 113. 1,320. 1,309. 1,307.
24 Total premium tax credit. Enter the amount from line 11(e) or add lines 12(e) through 23(e) and enter the total here 24 11,564.
25 Advance payment of PTC. Enter the amount from line 11(f) or add lines 12(f) through 23(f) and enter the total here 25 10,254.
26 Net premium tax credit. If line 24 is greater than line 25, subtract line 25 from line 24. Enter the difference here and
on Schedule 3 (Form 1040), line 9. If line 24 equals line 25, enter -0-. Stop here. If line 25 is greater than line 24,
leave this line blank and continue to line 27 26 1,310.
Part III Repayment of Excess Advance Payment of the Premium Tax Credit
27 Excess advance payment of PTC. If line 25 is greater than line 24, subtract line 24 from line 25. Enter the difference here 27
28 Repayment limitation (see instructions) 28
29 Excess advance premium tax credit repayment. Enter the smaller of line 27 or line 28 here and on Schedule 2
(Form 1040), line 2 29
For Paperwork Reduction Act Notice, see your tax return instructions. Form 8962 (2021)
UYA
Form 8962 (2021)
RENATO L and LEONILA S MARMITO 608-79-4506 Page 2
Part IV Allocation of Policy Amounts
Complete the following information for up to four policy amount allocations. See instructions for allocation details.
Allocation 1
30 (a) Policy Number (Form 1095-A, line 2) (b) SSN of other taxpayer (c) Allocation start month (d) Allocation stop month

Allocation percentage (g) Advance Payment of the PTC

applied to monthly (e) Premium Percentage (f) SLCSP Percentage
Percentage
amounts

Allocation 2
31 (a) Policy Number (Form 1095-A, line 2) (b) SSN of other taxpayer (c) Allocation start month (d) Allocation stop month

Allocation percentage (g) Advance Payment of the PTC

applied to monthly (e) Premium Percentage (f) SLCSP Percentage
Percentage
amounts

Allocation 3
32 (a) Policy Number (Form 1095-A, line 2) (b) SSN of other taxpayer (c) Allocation start month (d) Allocation stop month

Allocation percentage (g) Advance Payment of the PTC

applied to monthly (e) Premium Percentage (f) SLCSP Percentage
Percentage
amounts

Allocation 4
33 (a) Policy Number (Form 1095-A, line 2) (b) SSN of other taxpayer (c) Allocation start month (d) Allocation stop month

Allocation percentage (g) Advance Payment of the PTC

applied to monthly (e) Premium Percentage (f) SLCSP Percentage
Percentage
amounts

34 Have you completed all policy amount allocations?

Yes. Multiply the amounts on Form 1095-A by the allocation percentages entered by policy. Add all allocated policy amounts and non-
allocated policy amounts from Forms 1095-A, if any, to compute a combined total for each month. Enter the combined total for each month on
lines 12–23, columns (a), (b), and (f). Compute the amounts for lines 12–23, columns (c)–(e), and continue to line 24.

No. See the instructions to report additional policy amount allocations.

Part V Alternative Calculation for Year of Marriage
Complete line(s) 35 and/or 36 to elect the alternative calculation for year of marriage. For eligibility to make the election, see the instructions for line 9.
To complete line(s) 35 and/or 36 and compute the amounts for lines 12-23, see the instructions for this Part V.
35 Alternative entries (a) Alternative family size (b) Alternative monthly
contribution amount (c) Alternative start month (d) Alternative stop month
for your SSN

36 Alternative entries (a) Alternative family size (b) Alternative monthly (c) Alternative start month (d) Alternative stop month
contribution amount
for your spouse's
SSN
UYA Form 8962 (2021)
 Details for Schedule A, Line 11

RENATO L and LEONILA S MARMITO

608-79-4506 - 729-20-9294

Date Description Amount

————————————————————————————————————————————————————————————————————————
AMERICA NEEDS FATIMA 75.00
————————————————————————————————————————————————————————————————————————
Total 75.00
Form 8879 IRS e-file Signature Authorization
OMB No. 1545-0074
(Rev. January 2021)
ERO must obtain and retain completed Form 8879.
Department of the Treasury
Internal Revenue Service Go to www.irs.gov/Form8879 for the latest information.

Submission Identification Number (SID)

Taxpayer's name Social security number

RENATO L MARMITO 608-79-4506

Spouse's name Spouse's social security number

LEONILA S MARMITO 729-20-9294

Part I Tax Return Information —Tax Year Ending December 31, 2021(Enter year you are authorizing.)
Enter whole dollars only on lines 1 through 5.
Note: Form 1040-SS filers use line 4 only. Leave lines 1, 2, 3, and 5 blank.
1 Adjusted gross income 1 55,348.
2 Total tax 2 2,223.
3 Federal income tax withheld from Form(s) W-2 and Form(s) 1099 3 8,029.
4 Amount you want refunded to you 4 7,116.
5 Amount you owe 5
Part II Taxpayer Declaration and Signature Authorization (Be sure you get and keep a copy of your return)
Under penalties of perjury, I declare that I have examined a copy of the income tax return (original or amended) I am now authorizing, and to the best of
my knowledge and belief, it is true, correct, and complete. I further declare that the amounts in Part I above are the amounts from the income tax
return (original or amended) I am now authorizing. I consent to allow my intermediate service provider, transmitter, or electronic return originator (ERO)
to send my return to the IRS and to receive from the IRS (a) an acknowledgement of receipt or reason for rejection of the transmission, (b) the reason
for any delay in processing the return or refund, and (c) the date of any refund. If applicable, I authorize the U.S. Treasury and its designated Financial
Agent to initiate an ACH electronic funds withdrawal (direct debit) entry to the financial institution account indicated in the tax preparation software for
payment of my federal taxes owed on this return and/or a payment of estimated tax, and the financial institution to debit the entry to this account. This
authorization is to remain in full force and effect until I notify the U.S. Treasury Financial Agent to terminate the authorization. To revoke (cancel) a payment,
I must contact the U.S. Treasury Financial Agent at 1-888-353-4537. Payment cancellation requests must be received no later than 2 business days prior to
the payment (settlement) date. I also authorize the financial institutions involved in the processing of the electronic payment of taxes to receive confidential
information necessary to answer inquiries and resolve issues related to the payment. I further acknowledge that the personal identification number (PIN)
below is my signature for the income tax return (original or amended) I am now authorizing and, if applicable, my Electronic Funds Withdrawal Consent.

Taxpayer's PIN: check one box only

X I authorize VICENTE A. LOBEDERIO JR to enter or generate my PIN 71963
ERO firm name
Enter five digits, but
as my signature on the income tax return (original or amended) I am now authorizing. don't enter all zeros

I will enter my PIN as my signature on the income tax return (original or amended) I am now authorizing. Check this box
only if you are entering your own PIN and your return is filed using the Practitioner PIN method. The ERO must complete
Part III below.
Date

Spouse's PIN: check one box only

X I authorize VICENTE A. LOBEDERIO JR to enter or generate my PIN 01964
ERO firm name
Enter five digits, but
as my signature on the income tax return (original or amended) I am now authorizing. don't enter all zeros

I will enter my PIN as my signature on the income tax return (original or amended) I am now authorizing. Check this box
only if you are entering your own PIN and your return is filed using the Practitioner PIN method. The ERO must complete
Part III below.
Date

Practitioner PIN Method Returns Only— continue below

Part III Certification and Authentication – Practitioner PIN Method Only

ERO's EFIN/PIN. Enter your six-digit EFIN followed by your five-digit self-selected PIN. 30689601932
Don't enter all zeros
I certify that the above numeric entry is my PIN, which is my signature for the electronic individual income tax return (original or amended) I am now
authorized to file for tax year indicated above for the taxpayer(s) indicated above. I confirm that I am submitting this return in accordance with the
of the Practitioner PIN method and Pub. 1345, Handbook for Authorized IRS e-file Providers of Individual Income Tax Returns.
VICENTE A LOBEDERIO Date 02/02/2023
ERO Must Retain This Form – See Instructions
Don't Submit This Form to the IRS Unless Requested To Do So
For Paperwork Reduction Act Notice, see your tax return instructions. Form 8879 (Rev. 01-2021)
UYA
Form 8879 IRS e-file Signature Authorization
OMB No. 1545-0074
(Rev. January 2021)
ERO must obtain and retain completed Form 8879.
Department of the Treasury
Internal Revenue Service Go to www.irs.gov/Form8879 for the latest information.

Submission Identification Number (SID)

Taxpayer's name Social security number

RENATO L MARMITO 608-79-4506

Spouse's name Spouse's social security number

LEONILA S MARMITO 729-20-9294

Part I Tax Return Information —Tax Year Ending December 31, 2021(Enter year you are authorizing.)
Enter whole dollars only on lines 1 through 5.
Note: Form 1040-SS filers use line 4 only. Leave lines 1, 2, 3, and 5 blank.
1 Adjusted gross income 1 55,348.
2 Total tax 2 2,223.
3 Federal income tax withheld from Form(s) W-2 and Form(s) 1099 3 8,029.
4 Amount you want refunded to you 4 7,116.
5 Amount you owe 5
Part II Taxpayer Declaration and Signature Authorization (Be sure you get and keep a copy of your return)
Under penalties of perjury, I declare that I have examined a copy of the income tax return (original or amended) I am now authorizing, and to the best of
my knowledge and belief, it is true, correct, and complete. I further declare that the amounts in Part I above are the amounts from the income tax
return (original or amended) I am now authorizing. I consent to allow my intermediate service provider, transmitter, or electronic return originator (ERO)
to send my return to the IRS and to receive from the IRS (a) an acknowledgement of receipt or reason for rejection of the transmission, (b) the reason
for any delay in processing the return or refund, and (c) the date of any refund. If applicable, I authorize the U.S. Treasury and its designated Financial
Agent to initiate an ACH electronic funds withdrawal (direct debit) entry to the financial institution account indicated in the tax preparation software for
payment of my federal taxes owed on this return and/or a payment of estimated tax, and the financial institution to debit the entry to this account. This
authorization is to remain in full force and effect until I notify the U.S. Treasury Financial Agent to terminate the authorization. To revoke (cancel) a payment,
I must contact the U.S. Treasury Financial Agent at 1-888-353-4537. Payment cancellation requests must be received no later than 2 business days prior to
the payment (settlement) date. I also authorize the financial institutions involved in the processing of the electronic payment of taxes to receive confidential
information necessary to answer inquiries and resolve issues related to the payment. I further acknowledge that the personal identification number (PIN)
below is my signature for the income tax return (original or amended) I am now authorizing and, if applicable, my Electronic Funds Withdrawal Consent.

Taxpayer's PIN: check one box only

X I authorize VICENTE A. LOBEDERIO JR to enter or generate my PIN 71963
ERO firm name
Enter five digits, but
as my signature on the income tax return (original or amended) I am now authorizing. don't enter all zeros

I will enter my PIN as my signature on the income tax return (original or amended) I am now authorizing. Check this box
only if you are entering your own PIN and your return is filed using the Practitioner PIN method. The ERO must complete
Part III below.
Date

Spouse's PIN: check one box only

X I authorize VICENTE A. LOBEDERIO JR to enter or generate my PIN 01964
ERO firm name
Enter five digits, but
as my signature on the income tax return (original or amended) I am now authorizing. don't enter all zeros

I will enter my PIN as my signature on the income tax return (original or amended) I am now authorizing. Check this box
only if you are entering your own PIN and your return is filed using the Practitioner PIN method. The ERO must complete
Part III below.
Date

Practitioner PIN Method Returns Only— continue below

Part III Certification and Authentication – Practitioner PIN Method Only

ERO's EFIN/PIN. Enter your six-digit EFIN followed by your five-digit self-selected PIN. 30689601932
Don't enter all zeros
I certify that the above numeric entry is my PIN, which is my signature for the electronic individual income tax return (original or amended) I am now
authorized to file for tax year indicated above for the taxpayer(s) indicated above. I confirm that I am submitting this return in accordance with the
of the Practitioner PIN method and Pub. 1345, Handbook for Authorized IRS e-file Providers of Individual Income Tax Returns.
VICENTE A LOBEDERIO Date 02/02/2023
ERO Must Retain This Form – See Instructions
Don't Submit This Form to the IRS Unless Requested To Do So
For Paperwork Reduction Act Notice, see your tax return instructions. Form 8879 (Rev. 01-2021)
UYA
 TAXABLE YEAR FORM

2021 540
ATTACH FEDERAL RETURN

608-79-4506 MARM 729-20-9294 21

RENATO L MARMITO
LEONILA S MARMITO

2235 E 12TH ST
NATIONAL CITY CA 91950

04-27-1963 02-20-1964

Enter your county at time of filing (see instructions)

SAN DIEGO
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
Filing Status

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

2 X Married/RDP filing jointly. See inst. 5 Qualifying widow(er). 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 inst 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 2 X $129 = $ 258
8 Blind: If you (or your spouse/RDP) are visually impaired, enter 1;
if both are visually impaired, enter 2 8 X $129 = $
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 $129 = $

031 3101214 Form 540 2021 Side 1

Your name: MARMITO Your SSN or ITIN: 608-79-4506
10 Dependents: Do not include yourself or your spouse/RDP.
Dependent 1 Dependent 2 Dependent 3
First Name RYUICHI CRESENCIA
Last Name
MARMITO MARMITO
Exemptions

SSN. See
instructions. 729247933 556853366
Dependent's
relationship SON PARENT
to you

Total dependent exemptions 10 2 X $400 = $ 800

11 Exemption amount: Add line 7 through line 10. Transfer this amount to line 32 11 $ 1,058

12 State wages from your federal

Form(s) W-2, box 16 12 55,332 . 00

13 Enter federal adjusted gross income from federal Form 1040 or 1040-SR, line 11 13 55,348 . 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.
See instructions 15 55,348
Taxable Income

. 00
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 55,348 . 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 $4,803
Married/RDP filing jointly, Head of household, or Qualifying widow(er) $9,606
If Married/RDP filing separately or the box on line 6 is checked, STOP. See instructions 18 9,606 . 00
19 Subtract line 18 from line 17. This is your taxable income .
If less than zero, enter -0- 19 45,742 . 00

X Tax Table Tax Rate Schedule

31 Tax. Check the box if from:
FTB 3800 FTB 3803 31 757 . 00
32 Exemption credits. Enter the amount from line 11. If your federal AGI is more than
$212,288, see instructions 32 1,058 . 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 . 00

43 Enter credit name code and amount 43 . 00

44 Enter credit name code and amount 44 . 00

Side 2 Form 540 2021 031 3102214

Your name: MARMITO Your SSN or ITIN: 608-79-4506

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 . 00

47 Add line 40 through line 46. These are your total credits 47 0 . 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 Excess Advance Premium Assistance Subsidy (APAS) repayment. See instructions 64 116 . 00

65 Add line 48, line 61, line 62, line 63, and line 64. This is your total tax 65 116 . 00

71 California income tax withheld. See instructions 71 759 . 00

72 2021 CA estimated tax and other payments. See instructions 72 . 00

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

Payments

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

75 Earned Income Tax Credit (EITC) 75 . 00

76 Young Child Tax Credit (YCTC). See instructions 76 . 00

77 Net Premium Assistance Subsidy (PAS). See instructions 77 . 00

78 Add line 71 through line 77. These are your total payments.
See instructions 78 759 . 00
Use Tax

91 Use Tax. Do not leave blank. See instructions 91 0 . 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

IRS

If you did not check the box, see instructions.

Individual Shared Responsibility (ISR) Penalty. See instructions 92 0 . 00
Overpaid Tax/Tax Due

93 Payments balance. If line 78 is more than line 91, subtract line 91 from line 78 93 759 . 00

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 95 759 . 00
96 Individual Shared Responsibility Penalty Balance. If line 92 is more than line 93, then
subtract line 93 from line 92 96 . 00

031 3103214 Form 540 2021 Side 3

Your name: MARMITO Your SSN or ITIN: 608-79-4506
Overpaid Tax/Tax Due

97 Overpaid tax. If line 95 is more than line 65, subtract line 65 from line 95 97 643 . 00

98 Amount of line 97 you want applied to your 2022 estimated tax 98 . 00

99 Overpaid tax available this year. Subtract line 98 from line 97 99 643 . 00

100 Tax due. If line 95 is less than line 65, subtract line 95 from line 65 100 . 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

Schools Not Prisons Voluntary Tax Contribution Fund 443 . 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 code 400 through code 446. This is your total contribution 110 . 00

Side 4 Form 540 2021 031 3104214

Your name: MARMITO Your SSN or ITIN: 608-79-4506
You Owe

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.
Amount

Mail to: FRANCHISE TAX BOARD, PO BOX 942867, SACRAMENTO CA 94267-0001 111 0 . 00
Pay Online – Go to ftb.ca.gov/pay for more information.

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 115 643 . 00
Refund and Direct Deposit

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 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

256074974 7056987634 643 . 00
Savings

The remaining amount of my refund (line 115) is authorized for direct deposit into the account shown below:
Type
Routing number Account number 117 Direct deposit amount
Checking
. 00
Savings

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/forms 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 Spouse's/RDP's signature (if a joint tax return, both must sign)

Your email address. Enter only one email address. Preferred phone number
619-753-0833
Sign
Paid preparer's signature (declaration of preparer is based on all information of which preparer has any knowledge)
Here
VICENTE A LOBEDERIO
It is unlawful
to forge a Firm's name (or yours, if self-employed) PTIN
spouse's/
RDP's VICENTE A. LOBEDERIO JR P00752775
signature.
Firm's address Firm's FEIN
Joint tax
return? 7442 GRIBBLE ST SAN DIEGO, CA 92114
(See
instructions) Do you want to allow another person to discuss this tax return with us? See instructions X Yes No

Print Third Party Designee's Name Telephone Number

VICENTE LOBEDERIO 619-274-2150

031 3105214 Form 540 2021 Side 5

TAXABLE YEAR CALIFORNIA SCHEDULE

2021 Wage and Tax Statement W-2

Important: Attach this schedule to the back of your original or amended Form 540, 540 2EZ, or 540NR.
Caution: If this schedule is filled out, do not send your federal Form(s) W-2 to the Franchise Tax Board. If your federal Form(s) W-2 are from
multiple states, attach copies showing California tax withheld to this schedule. If this schedule is blank, attach your federal Form(s) W-2 to the
lower front of your tax return. DO NOT ATTACH PAYMENT TO THIS SCHEDULE.
*Employee’s social security number, name, and address must be the same as the information on federal Form(s) W-2.

W-2 Information
a. Employee’s social security number* c. Employer's name

608794506 MLY WHOLE FOODS INC

b. Employer identification number (EIN) Employer's address

571209397 1420 E PLAZA BLVD SUITE 07

City State ZIP code

NATIONAL CITY CA 91950

e. Employee’s first name* Initial* Last name* Suffix*

RENATO L MARMITO
f. Employee's address*

2235 E 12TH ST
City* State* ZIP code*

NATIONAL CITY CA 91950

Wages, tips, other compensation Social security tax withheld Allocated tips (not included in box 1)

1.
28,274 4.
1,753 8.
Federal income tax withheld Medicare tax withheld Dependent care benefits

2. 6,489 6. 410 10.

Social security wages Social security tips Nonqualified plans

3. 28,274 7. 11.

12. Codes and amounts

Code Amount Code Amount

12a. 12c.

Code Amount Code Amount

12b. 12d.

13. Check the appropriate box for: Statutory employee, Retirement plan, or Third-party sick pay

Statutory employee Retirement plan Third-party sick pay

14. SDI, VPDI, or CA SDI (from federal Form W-2, box 14 or 19)
Type Amount 16. State wages, tips, etc.

28,274

15. State and employer’s state ID number

State Employer’s state ID number 17. State income tax

CA CA 250-2399-5 325

031 8041214 Schedule W-2 2021

TAXABLE YEAR CALIFORNIA SCHEDULE

2021 Wage and Tax Statement W-2

Important: Attach this schedule to the back of your original or amended Form 540, 540 2EZ, or 540NR.
Caution: If this schedule is filled out, do not send your federal Form(s) W-2 to the Franchise Tax Board. If your federal Form(s) W-2 are from
multiple states, attach copies showing California tax withheld to this schedule. If this schedule is blank, attach your federal Form(s) W-2 to the
lower front of your tax return. DO NOT ATTACH PAYMENT TO THIS SCHEDULE.
*Employee’s social security number, name, and address must be the same as the information on federal Form(s) W-2.

W-2 Information
a. Employee’s social security number* c. Employer's name

608794506 FORTUNE COMMERCIAL CORP

b. Employer identification number (EIN) Employer's address

330364926 2883 SURVEYOR ST

City State ZIP code

POMONA CA 91768
e. Employee’s first name* Initial* Last name* Suffix*

RENATO L MARMITO
f. Employee's address*

2235 E 12TH ST
City* State* ZIP code*

NATIONAL CITY CA 91950

Wages, tips, other compensation Social security tax withheld Allocated tips (not included in box 1)

1.
27,024 4.
1,676 8.
Federal income tax withheld Medicare tax withheld Dependent care benefits

2. 1,539 6. 392 10.

Social security wages Social security tips Nonqualified plans

3. 27,024 7. 11.

12. Codes and amounts

Code Amount Code Amount

12a. 12c.

Code Amount Code Amount

12b. 12d.

13. Check the appropriate box for: Statutory employee, Retirement plan, or Third-party sick pay

Statutory employee Retirement plan Third-party sick pay

14. SDI, VPDI, or CA SDI (from federal Form W-2, box 14 or 19)
Type Amount 16. State wages, tips, etc.

27,024

15. State and employer’s state ID number

State Employer’s state ID number 17. State income tax

CA 365-7593 4 434

031 8041214 Schedule W-2 2021

TAXABLE YEAR CALIFORNIA SCHEDULE

2021 Wage and Tax Statement W-2

Important: Attach this schedule to the back of your original or amended Form 540, 540 2EZ, or 540NR.
Caution: If this schedule is filled out, do not send your federal Form(s) W-2 to the Franchise Tax Board. If your federal Form(s) W-2 are from
multiple states, attach copies showing California tax withheld to this schedule. If this schedule is blank, attach your federal Form(s) W-2 to the
lower front of your tax return. DO NOT ATTACH PAYMENT TO THIS SCHEDULE.
*Employee’s social security number, name, and address must be the same as the information on federal Form(s) W-2.

W-2 Information
a. Employee’s social security number* c. Employer's name

729209294 WAL-MART ASSOCIATES, INC.

b. Employer identification number (EIN) Employer's address

710794409 702 SW 8TH STREET

City State ZIP code

BENTONVILLE AR 72716-0135
e. Employee’s first name* Initial* Last name* Suffix*

LEONILA S MARMITO
f. Employee's address*

2235 E 12TH ST
City* State* ZIP code*

NATIONAL CITY CA 91950

Wages, tips, other compensation Social security tax withheld Allocated tips (not included in box 1)

1.
34 4.
2 8.
Federal income tax withheld Medicare tax withheld Dependent care benefits

2. 6. 1 10.

Social security wages Social security tips Nonqualified plans

3. 34 7. 11.

12. Codes and amounts

Code Amount Code Amount

12a. 12c.

Code Amount Code Amount

12b. 12d.

13. Check the appropriate box for: Statutory employee, Retirement plan, or Third-party sick pay

Statutory employee Retirement plan Third-party sick pay

14. SDI, VPDI, or CA SDI (from federal Form W-2, box 14 or 19)
Type Amount 16. State wages, tips, etc.

CA SDI 34

15. State and employer’s state ID number

State Employer’s state ID number 17. State income tax

CA 427 5978 7

031 8041214 Schedule W-2 2021

TAXABLE YEAR CALIFORNIA FORM

2021 Premium Assistance Subsidy 3849

Attach to your California Form 540 or Form 540NR.
Name(s) as shown on your California tax return SSN or ITIN
RENATO L AND LEONILA S MARMITO 608-79-4506
You are not eligible to take the Premium Assistance Subsidy (PAS) if your filing status is married filing separately unless you
qualify for an exception (see instructions). If you qualify for an exception, check the box.
Part I Annual and Monthly Contribution Amount

1 Applicable household size. Enter your applicable household size. See instructions 1 4
2a Modified AGI. Enter your modified AGI. See instructions 2a 55,348
b Enter the total of your dependents’ modified AGI. See instructions 2b
3 Household income. Add the amounts on lines 2a and 2b. See instructions 3 55,348
4 Federal poverty line. Enter the federal poverty line amount from Table 1-1. See instructions 4 26,200
5 Household income as a percentage of federal poverty line. See instructions 5 211.00%
6
X No. Continue to line 7.
Yes. You are not eligible to take the PAS. If advance payment of the PAS was made,
see the instructions for how to report your excess advance PAS repayment amount.
7 CA applicable figure. Using your line 5 percentage, locate your "CA applicable figure" from Table 2. See instructions 7 0.06583
8a Annual contribution amount. Multiply line 3 by line 7. Round to nearest whole dollar amount 8a 3,644
b Monthly contribution amount. Divide line 8a by 12. Round to nearest whole dollar amount 8b 304
Part II Premium Assistance Subsidy Claim and Reconciliation of Advance Payment of Premium Assistance Subsidy

9 Are you allocating policy amounts with another taxpayer or do you want to use the alternative calculation for year of marriage (see instructions)?
Yes. Skip to Part IV, Allocation of Policy Amounts, or Part V, Alternative Calculation X No. Continue to line 10.
for Year of Marriage.
10 See the instructions to determine whether you should check the “Yes” box or “No” box, and then proceed as directed.
Yes. Continue to line 11. Compute your annual PAS. Then skip lines 12 through 23 X No. Continue to lines 12 through 23. Compute
and continue to line 24. your monthly PAS and continue to line 24.
(a) (b) (c) (d) (e) (f) (g)

Annual
Calculation

11 Annual Totals
(a) (b) (c) (d) (e) (f) (g)

Monthly
Calculation

12 January 701 701 304 588 20

13 February 701 701 304 588 20
14 March 1,309 304 19
15 April 1,309 304 19
16 May 1,309 304 19
17 June 1,309 304 19
18 July
19 August
20 September 1,309 304
21 October 1,309 304
22 November 1,309 304
23 December 1,309 304

For Privacy Notice, get FTB 1131 EN-SP. 031 8671214 FTB 3849 2021 Side 1
24 Total PAS. Enter the amount from line 11(f) or add lines 12(f) through 23(f) and enter the total here 24
25 Advance payment of PAS. Enter the amount from line 11(g) or add lines 12(g) through 23(g) and enter the total here 25 116
26 Net PAS. If line 24 is greater than line 25, subtract line 25 from line 24. Enter the difference here and on Form 540, line 77, or
Form 540NR, line 87. If line 24 equals line 25, enter -0-. Stop here.
If line 25 is greater than line 24, leave this line blank and continue to line 27 26
Part III Repayment of Excess Advance Payment of the Premium Assistance Subsidy
27 Excess advance payment of PAS. If line 25 is greater than line 24, subtract line 24 from line 25. Enter the difference here 27 116
28 Repayment limitation. See instructions 28 1,550
Check this box if the "Repayment cap may not apply" box on form FTB 3895 is also checked.
29 Excess PAS repayment. Enter the smaller of line 27 or line 28 here and on Form 540, line 64,
or Form 540NR, line 74 29 116
Part IV Allocation of Policy Amounts
Complete the following information for up to four policy amount allocations. See instructions for allocation details.
Allocation 1
30 (a) (b) (c) (d)
Market-assigned policy number (Form FTB 3895) SSN or ITIN of other taxpayer Allocation start month Allocation stop month

Allocation percentage applied to monthly (e) (f) (g)

amounts Premium Percentage SLCSP Percentage Advance Payment of the PAS Percentage

Allocation 2
31 (a) (b) (c) (d)
Market-assigned policy number (Form FTB 3895) SSN or ITIN of other taxpayer Allocation start month Allocation stop month

Allocation percentage applied to monthly (e) (f) (g)

amounts Premium Percentage SLCSP Percentage Advance Payment of the PAS Percentage

Allocation 3
32 (a) (b) (c) (d)
Market-assigned policy number (Form FTB 3895) SSN or ITIN of other taxpayer Allocation start month Allocation stop month

Allocation percentage applied to monthly (e) (f) (g)

amounts Premium Percentage SLCSP Percentage Advance Payment of the PAS Percentage

Allocation 4
33 (a) (b) (c) (d)
Market-assigned policy number (Form FTB 3895) SSN or ITIN of other taxpayer Allocation start month Allocation stop month

Allocation percentage applied to monthly (e) (f) (g)

amounts Premium Percentage SLCSP Percentage Advance Payment of the PAS Percentage

34 Have you completed all policy amount allocations?

Yes. Multiply the amounts on form FTB 3895 by the allocation percentages entered by policy. Add all allocated policy amounts and non-allocated
policy amounts from forms FTB 3895, if any, to compute a combined total for each month. Enter the combined total for each month on lines 12
through 23, columns (a), (b), and (f). Compute the amounts for lines 12 through 23, columns (c) through (e), and continue to line 24.
No. See the instructions to report additional policy amount allocations.
Part V Alternative Calculation for Year of Marriage
Complete line(s) 35 and/or 36 to elect the alternative calculation for year of marriage. For eligibility to make the election, see the instructions for line 9.
To complete line(s) 35 and/or 36 and compute the amounts for lines 12 through 23, see the instructions for Part V.
(a) (b) (c) (d)
35 Alternative entries for you Alternative household size Alternative monthly contribution amount Alternative start month Alternative stop month

0
(a) (b) (c) (d)
Alternative entries for your Alternative household size Alternative monthly contribution amount Alternative start month Alternative stop month
36 spouse/ RDP
0

Side 2 FTB 3849 2021 031 8672214

031 DO NOT MAIL THIS FORM TO THE FTB
TAXABLE YEAR FORM

2021 California e-file Signature Authorization for Individuals 8879

Your name Your SSN or ITIN
RENATO L MARMITO 608-79-4506
Spouse's/RDP's name Spouse's/RDP's SSN or ITIN
LEONILA S MARMITO 729-20-9294
Part I Tax Return Information (whole dollars only)

1 California adjusted gross income (AGI). See instructions 1 55,348.

2 Amount You Owe. See instructions. 2

3 Refund or No Amount Due. See instructions. 3 643.

Part II Taxpayer Declaration and Signature Authorization (Be sure you obtain and keep a copy of your return.)
Under penalties of perjury, I declare that I have examined a copy of my individual income tax return and accompanying schedules and statements for the tax
year ending December 31, 2021, and to the best of my knowledge and belief, it is true, correct, and complete. I further declare that the information I
provided to my electronic return originator (ERO), transmitter, or intermediate service provider, including my name, address, and social security number (SSN)
or individual tax identification number (ITIN), and the amounts shown in Part I above agree with the information and amounts shown on the corresponding lines
of my electronic income tax return. If applicable, I authorize an electronic funds withdrawal of the amount on line 2 and/or the estimated tax payments as
shown on my return and on form FTB 8455, California e-file Payment Record for Individuals, or a comparable form. If applicable, I declare that direct deposit
refund amount on line 3 agrees with the direct deposit authorization stated on my return. If I have filed a joint return, this is an irrevocable appointment of the
other spouse/registered domestic partner (RDP) as an agent to authorize an electronic funds withdrawal or direct deposit. I authorize my ERO, transmitter, or
intermediate service provider to transmit my complete return to the Franchise Tax Board (FTB). If the processing of my return or refund is delayed, I
authorize the FTB to disclose to my ERO, intermediate service provider, and/or transmitter the reason(s) for the delay or the date when the
refund was sent. If I am filing a balance due return, I understand that if the FTB does not receive full and timely payment of my tax liability, I remain liable
for the tax liability and all applicable interest and penalties. I acknowledge that I have read and consent to the Electronic Funds Withdrawal Consent included
on the copy of my electronic income tax return. I have selected a personal identification number (PIN) as my signature for my electronic income tax return and,
if applicable, my Electronic Funds Withdrawal Consent.

Taxpayer's PIN: check one box only

X I authorize VICENTE A. LOBEDERIO JR to enter my PIN
ERO firm name Do not enter all zeros
as my signature on my 2021 e-filed California individual income tax return.

I will enter my PIN as my signature on my 2021 e-filed California individual income tax return. Check this box only if you are entering your own PIN and
your return is filed using the Practitioner PIN method. The ERO must complete Part III below.
Your signature Date

Spouse's/RDP's PIN: check one box only

X I authorize VICENTE A. LOBEDERIO JR to enter my PIN
ERO firm name Do not enter all zeros
as my signature on my 2021 e-filed California individual income tax return.

I will enter my PIN as my signature on my 2021 e-filed California individual income tax return. Check this box only if you are entering your own PIN
and your return is filed using the Practitioner PIN method. The ERO must complete Part III below.
Spouse's/RDP's signature Date

Practitioner PIN Method Returns Only - continue below

Part III Certification and Authentication - Practitioner PIN Method Only
ERO's Electronic Filer Identification Number (EFIN)/PIN.
Enter your six-digit EFIN followed by your five-digit self-selected PIN. 3 0 6 8 9 6 0 1 9 3 2
Do not enter all zeros
I certify that the above numeric entry is my PIN, which is my signature for the 2021 California individual income tax return for the taxpayer(s) indicated above.
I confirm that I am submitting this return in accordance with the requirements of the Practitioner PIN method and FTB Pub. 1345, 2021 Handbook for Authorized
e-file Providers.
ERO's signature VICENTE A LOBEDERIO Date

For Privacy Notice, get FTB 1131 EN-SP. FTB 8879 2021
031 DO NOT MAIL THIS FORM TO THE FTB
TAXABLE YEAR FORM

2021 California e-file Signature Authorization for Individuals 8879

Your name Your SSN or ITIN
RENATO L MARMITO 608-79-4506
Spouse's/RDP's name Spouse's/RDP's SSN or ITIN
LEONILA S MARMITO 729-20-9294
Part I Tax Return Information (whole dollars only)

1 California adjusted gross income (AGI). See instructions 1 55,348.

2 Amount You Owe. See instructions. 2

3 Refund or No Amount Due. See instructions. 3 643.

Part II Taxpayer Declaration and Signature Authorization (Be sure you obtain and keep a copy of your return.)
Under penalties of perjury, I declare that I have examined a copy of my individual income tax return and accompanying schedules and statements for the tax
year ending December 31, 2021, and to the best of my knowledge and belief, it is true, correct, and complete. I further declare that the information I
provided to my electronic return originator (ERO), transmitter, or intermediate service provider, including my name, address, and social security number (SSN)
or individual tax identification number (ITIN), and the amounts shown in Part I above agree with the information and amounts shown on the corresponding lines
of my electronic income tax return. If applicable, I authorize an electronic funds withdrawal of the amount on line 2 and/or the estimated tax payments as
shown on my return and on form FTB 8455, California e-file Payment Record for Individuals, or a comparable form. If applicable, I declare that direct deposit
refund amount on line 3 agrees with the direct deposit authorization stated on my return. If I have filed a joint return, this is an irrevocable appointment of the
other spouse/registered domestic partner (RDP) as an agent to authorize an electronic funds withdrawal or direct deposit. I authorize my ERO, transmitter, or
intermediate service provider to transmit my complete return to the Franchise Tax Board (FTB). If the processing of my return or refund is delayed, I
authorize the FTB to disclose to my ERO, intermediate service provider, and/or transmitter the reason(s) for the delay or the date when the
refund was sent. If I am filing a balance due return, I understand that if the FTB does not receive full and timely payment of my tax liability, I remain liable
for the tax liability and all applicable interest and penalties. I acknowledge that I have read and consent to the Electronic Funds Withdrawal Consent included
on the copy of my electronic income tax return. I have selected a personal identification number (PIN) as my signature for my electronic income tax return and,
if applicable, my Electronic Funds Withdrawal Consent.

Taxpayer's PIN: check one box only

X I authorize VICENTE A. LOBEDERIO JR to enter my PIN
ERO firm name Do not enter all zeros
as my signature on my 2021 e-filed California individual income tax return.

I will enter my PIN as my signature on my 2021 e-filed California individual income tax return. Check this box only if you are entering your own PIN and
your return is filed using the Practitioner PIN method. The ERO must complete Part III below.
Your signature Date

Spouse's/RDP's PIN: check one box only

X I authorize VICENTE A. LOBEDERIO JR to enter my PIN
ERO firm name Do not enter all zeros
as my signature on my 2021 e-filed California individual income tax return.

I will enter my PIN as my signature on my 2021 e-filed California individual income tax return. Check this box only if you are entering your own PIN
and your return is filed using the Practitioner PIN method. The ERO must complete Part III below.
Spouse's/RDP's signature Date

Practitioner PIN Method Returns Only - continue below

Part III Certification and Authentication - Practitioner PIN Method Only
ERO's Electronic Filer Identification Number (EFIN)/PIN.
Enter your six-digit EFIN followed by your five-digit self-selected PIN. 3 0 6 8 9 6 0 1 9 3 2
Do not enter all zeros
I certify that the above numeric entry is my PIN, which is my signature for the 2021 California individual income tax return for the taxpayer(s) indicated above.
I confirm that I am submitting this return in accordance with the requirements of the Practitioner PIN method and FTB Pub. 1345, 2021 Handbook for Authorized
e-file Providers.
ERO's signature VICENTE A LOBEDERIO Date

For Privacy Notice, get FTB 1131 EN-SP. FTB 8879 2021