Form 1 - Massachusetts Resident Income Tax Return - 2016 Page 3
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3File pg. 3
2016 FORM 1, PAGE 3
SOCIAL SECURITY NUMBER
FIRST NAME
M.I.
LAST NAME
33
Voluntary fund contributions:
0 0
0 0
a. Endangered Wildlife Conservation 3 33a
d. Massachusetts U.S. Olympic . . . . . . . 3 33d
0 0
0 0
b. Organ Transplant . . . . . . . . . . . . . 3 33b
e. Mass. Military Family Relief . . . . . . . . 3 33e
0 0
0 0
c. Massachusetts AIDS . . . . . . . . . . . 3 33c
f. Homeless Animal Prevention And Care 3 33f
0 0
Total. Add lines 33a through 33f . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
0 0
34
Use tax due on Internet, mail order and other out-of-state purchases (from worksheet) . . . . . . . . . 3 34
35
Health Care penalty. Not less than “0” (from worksheet; be sure to enclose Schedule HC):
0 0
0 0
0 0
0 0
a. 3
+ b. 3
– c. 3
. . . a + b – c = 35
You
Spouse
Federal healthcare penalty
0 0
36
INCOME TAX AFTER CREDITS, CONTRIBUTIONS, USE TAX and HC PENALTY. Add lines 32– 35 . . . . 36
37
Massachusetts income tax withheld (enclose all Massachusetts Forms W-2, W-2G, 2-G,
0 0
PWH-WA, LOA and certain 1099s, if applicable) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 37
38
2015 overpayment applied to your 2016 estimated tax (from 2015 Form 1, line 45 or
0 0
Form 1-NR/PY, line 50; do not enter 2015 refund) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 38
0 0
39
2016 Massachusetts estimated tax payments (do not include amount in line 38) . . . . . . . . . . . . . 3 39
0 0
40
Payments made with extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 40
41
Earned Income Credit:
0 0
0 0
a. Number of qualifying children 3
Amount from U.S. return 3
× .23 = . . . . 3 41
0 0
42
Senior Circuit Breaker Credit (enclose Schedule CB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 42
0 0
43
Other refundable credits (from Credit Manager Schedule). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 43
0 0
44
TOTAL. Add lines 37 through 43 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
45
OVERPAYMENT. If line 36 is smaller than line 44, subtract line 36 from line 44. If line 36 is larger
0 0
than line 44, go to line 48. If line 36 and line 44 are equal, enter “0” in line 47 . . . . . . . . . . . . . . . . 3 45
0 0
46
Amount of overpayment you want APPLIED to your 2017 ESTIMATED TAX . . . . . . . . . . . . . . . . . . 3 46
47
THIS IS YOUR REFUND. Subtract line 46 from line 45.
0 0
Mail to: Massachusetts DOR, PO Box 7000, Boston, MA 02204 . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 47
Direct Deposit of Refund. See instructions.
Type of account (you must select one): 3
Checking
Savings
3
3
Routing number (first two digits must be 01–12 or 21–32)
Account number
48
TAX DUE. Subtract line 44 from line 36. Pay online at mass.gov/masstaxconnect, or use
0 0
Form PV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 48
Pay in full. Write Social Security number(s) on lower left corner of check and be sure to sign check.
Make payable to Commonwealth of Massachusetts. Mail to: Massachusetts DOR, PO Box 7003, Boston, MA 02204.
Add to total in line 48, if applicable:
0 0
0 0
0 0
Interest 3
Penalty 3
M-2210 amount 3
Exception. Enclose Form M-2210
3
BE SURE TO SIGN RETURN ON PAGE 1 AND ENCLOSE SCHEDULE HC.
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