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2003

MISSOURI INDIVIDUAL INCOME TAX RETURN

FORM MO-1040B

MARRIED FILING COMBINED — SHORT FORM

LAST NAME

FIRST NAME

MIDDLE INITIAL

DECEASED

SOCIAL SECURITY NUMBER

SOFTWARE

VENDOR CODE

2003

(Assigned by DOR)

SPOUSE’S LAST NAME

FIRST NAME

MIDDLE INITIAL

DECEASED

SPOUSE’S SOCIAL SECURITY NUMBER

2003

IN CARE OF NAME (ATTORNEY, EXECUTOR, PERSONAL REPRESENTATIVE, ETC.)

COUNTY OF RESIDENCE

SCHOOL DISTRICT NO.

PRESENT ADDRESS (INCLUDE APARTMENT NO. OR RURAL ROUTE)

CITY, TOWN, OR POST OFFICE, STATE, AND ZIP CODE

AGE 65 OR OLDER

BLIND

100% DISABLED

NON-OBLIGATED SPOUSE

PLEASE CHECK THE APPROPRIATE

YOURSELF

BOXES THAT APPLY TO YOURSELF

OR YOUR SPOUSE.

SPOUSE

Yourself

Spouse

1. Federal adjusted gross income from your 2003 federal return

(See worksheet on page 8.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

–

2. Any state income tax refund included in your 2003 federal income . . . . . . . . . . . . . . . . .

3. Subtract Line 2 from Line 1. This is your Missouri Adjusted Gross Income. . . . . . .

4. Total Missouri Adjusted Gross Income — Add both numbers on Line 3. . . . . . . . . . . . . . . . . .

5. Income percentages: Divide Line 3 by Line 4 for both you and your spouse.

(The total of the two must equal 100%. Round to the nearest whole number.) . . . . . . . . . . . . . . .

6. Enter the exemption amount of $4,200 on Line 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7. Tax from federal return

Enter this amount on Line 7 or

(Do not enter amount from your

$10,000, whichever is less.

Form W-2(s)—NOT federal tax withheld.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8. Missouri standard deduction or itemized deductions. (Missouri standard deduction — $9,500)

If claimed as a dependent, age 65 or older, or blind, see federal return. If itemizing, see back of form.

9. Number of dependents you claimed on your Federal Form 1040 OR

1040A, Line 6c. (Do not include yourself or your spouse.) . . . . . . . . . . . .

x $1,200 =

10. Long-term care insurance deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11. Total Deductions — Add Lines 6 through 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12. Missouri Taxable Income — Subtract Line 11 from Line 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yourself

Spouse

13. Multiply Line 12 by the percentages on Line 5 for you and

your spouse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14. Use the tax table on back of this form to figure the

tax on amounts from Line 13 for you and your spouse. . . . . . . . . . . . . . . . . . . . . . .

15. Total Taxes — Add your tax and your spouse’s tax from Line 14. . . . . . . . . . . . . . . . . . . . . . . . .

16. Missouri tax withheld for you and your spouse from your Form W-2(s) and

Form 1099(s). Attach copies of Form W-2(s) and Form 1099(s). . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17. Any Missouri estimated tax payments you made for 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18. Total Payments — Add Lines 16 and 17. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19. If Line 18 (Total Payments) is more than Line 15 (Total Taxes), enter the difference

(amount of overpayment) here. (If Line 18 is less than Line 15, skip to Line 23.) . . . . . . . . . . .

20. Amount from Line 19 you want applied to next year’s taxes. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Children’s

Veterans

Elderly Home

Missouri National

General Revenue

Workers’

General

21. Enter the amount of your

Delivered Meals

Guard

Memorial

Workers

Revenue

donation in the trust fund

boxes to the right. . . . . . . . . . .

22. Subtract Lines 20 and 21 from Line 19 and enter here. This is your refund.

Sign below and mail to:

Department of Revenue,

P.O. Box 500, Jefferson City, MO 65106-0500.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.REFUND

23. If Line 18 is less than Line 15, enter the difference here. You have an amount due.

Sign below and mail to:

Department of Revenue,

P.O. Box 329, Jefferson City, MO 65107-0329.

. . . . . . . . . . . . . . . . . . . . . .

.AMOUNT YOU OWE

The Department of Revenue may collect checks returned for insufficient or uncollected funds electronically.

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief it is true, cor-

DOR

S E P

rect, and complete. Declaration of preparer (other than taxpayer) is based on all information of which he/she has any knowledge. As provided in Chapter 143, RSMo, a penalty of up

ONLY

to $500 shall be imposed on any individual who files a frivolous return.

PAID PREPARER’S PHONE

I authorize the Director of Revenue or delegate to discuss my return and attachments with the preparer or any member of the preparer’s firm.

YES

SIGNATURE

DATE

PAID PREPARER’S SIGNATURE

FEIN, SSN, OR PTIN

SPOUSE’S SIGNATURE

DAYTIME TELEPHONE

PAID PREPARER’S ADDRESS AND ZIP CODE