Form F-1040 - Flint - 2016 Page 2

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Taxpayer's name
Taxpayer's SSN
16MI-FLT2
F-1040, PAGE 2
EXEMPTIONS
Date of birth (mm/dd/yyyy)
Regular
65 or over
Blind
Deaf
Disabled
SCHEDULE
1e.
Enter the number of
1a. You
boxes checked on
1b. Spouse
lines 1a and 1b
1d. List Dependents
1c.
Check box if you can be claimed as a dependent on another person's tax return
1f.
Enter number of
First Name
Last Name
Relationship
Date of Birth
#
Social Security Number
dependent children
1
listed on line 1d
2
1g.
Enter number of other
3
dependents listed on
4
line 1d
5
1h.
Total exemptions (Add
6
lines 1e, 1f and 1g;
7
enter here and also on
page 1, line 21a)
8
EXCLUDED WAGES AND TAX WITHHELD SCHEDULE
(See instructions. Resident wages generally not excluded)
Col. A
COLUMN B
COLUMN C
COLUMN D
COLUMN E
COLUMN F
W-2
FAILURE TO
SOCIAL SECURITY NUMBER
EMPLOYER'S ID NUMBER
EXCLUDED WAGES
LOCALITY NAME
FLINT TAX WITHHELD
#
T or S
(Form W-2, box a)
(Form W-2, box b)
(Attach Excluded Wages Sch)
ATTACH W-2
(Form W-2, box 19)
(Form W-2, box 20)
.00
.00
1.
FORMS TO PAGE
1 WILL DELAY
.00
.00
2.
PROCESSING OF
.00
.00
3.
RETURN. WAGE
.00
.00
4.
INFORMATION
.00
STATEMENTS
.00
5.
PRINTED FROM
.00
.00
6.
TAX
.00
.00
7.
PREPARATION
SOFTWARE ARE
.00
.00
8.
NOT
.00
.00
9.
ACCEPTABLE.
.00
.00
10.
.00
.00
11.
Totals (Enter here and on page 1; part-yr residents on Sch TC)
<< Enter on pg 1, ln 1, col B
<< Enter on pg 1, ln 24a
DEDUCTIONS SCHEDULE (See instructions; deductions allocated on the same basis as related income)
DEDUCTIONS
.00
1. IRA deduction (Attach copy of page 1 of federal return & evidence of payment)
1
.00
2. Self-employed SEP, SIMPLE and qualified plans (Attach copy of page 1 of federal return)
2
.00
3. Employee business expenses (See instructions and attach copy of federal Form 2106)
3
.00
4. Moving expenses (Into Flint area only) (Attach copy of federal Form 3903)
4
.00
5. Alimony paid (DO NOT INCLUDE CHILD SUPPORT. Attach copy of page 1 of federal return)
5
.00
6. Renaissance Zone deduction (Attach Schedule RZ OF 1040)
6
.00
7.
Total deductions (Add line 1 through line 6, enter total here and on page 1, line 19)
7
ADDRESS SCHEDULE (Where taxpayer (T), spouse (S) or both (B) resided during year and dates of residency)
MARK
FROM
TO
ADDRESS (INCLUDE CITY, STATE & ZIP CODE) Start with address used on last year's return. If the address is the same as
listed on page 1 of this return, print "Same." If no return filed, list reason. Continue listing residence addresses from this year.
T, S, B
MONTH
DAY
MONTH
DAY
THIRD PARTY DESIGNEE
Do you want to allow another person to discuss this return with the Income Tax Office?
Yes, complete the following
No
Designee's
Phone
Personal identification
name
No.
number (PIN)
Under the penalty of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief it is
true, correct and complete. If prepared by a person other than taxpayer, the preparer's declaration is based on all information of which preparer has any knowledge.
SIGN
TAXPAYER'S SIGNATURE - If joint return, both spouses must sign
Date (MM/DD/YY)
Taxpayer's occupation
Daytime phone number
If deceased, date of death
HERE
===>
SPOUSE'S SIGNATURE
Date (MM/DD/YY)
Spouse's occupation
If deceased, date of death
SIGNATURE OF PREPARER OTHER THAN TAXPAYER
Date (MM/DD/YY)
PTIN, EIN or SSN
Preparer's phone no.
NACTP
FIRM'S NAME (or yours if self-employed), ADDRESS AND ZIP CODE
16
FLT
software
number
Revised: 12/27/2016

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