FORM
MARYLAND INCOME TAX DECLARATION
2001
EL101
FOR ELECTRONIC FILING
(or fiscal year beginning
2001, ending
)
See instructions on back
Taxpayer's first name and middle initial
Last name
Taxpayer identification number
Spouse’s first name and middle initial
Last name
Taxpayer identification number
Attach
Label
Present address (number and street)
City or town
State
ZIP code
Part I
Tax Return Information (whole dollars only)
1. Adjusted gross income from your federal return ...............................................................................................................
2. Taxable net income from your Maryland return ...............................................................................................................
3. Total Maryland income tax, local income tax and contributions (as applicable) ............................................................
4. Total payments and credits ................................................................................................................................................
5. Amount of overpayment to be applied to 2002 estimated tax ..........................................................................................
6. Amount of overpayment to be refunded to you .........................................................................................
REFUND
7. Total amount due (Pay in full by April 15, 2002. See instructions.) .................................................................................
Part II
Check appropriate box to consent to:
Direct Deposit of refund or
Electronic Funds Withdrawal (direct debit)
8a.
Type of account
Checking
Savings
8b.
Routing number
8c.
Account number
Attach
8d.
Direct Debit Settlement Date _____ / _____ / _____ (Enter the date you want your payment withdrawn from your account.)
Wage
and
I consent that my refund be directly deposited as designated above, and declare that the information shown is correct. If I have filed a joint
Tax
return, this is an irrevocable appointment of the other spouse as an agent to receive the refund. By consenting, I also agree to disclose to
Statements
the Maryland State Treasurer’s Office certain income tax information including name, amount of refund and the above bank information.
Here
This disclosure is necessary to effect direct deposit.
I authorize the State of Maryland and its designated financial agent to initiate an electronic funds withdrawal payment entry to the financial
institution account indicated for payment of my Maryland and local taxes owed, and the financial institution to debit the entry to this
account. Upon confirmation of consent during the filing of my state return, this authorization is to remain in full force and effect, and I may
not terminate the authorization. I also authorize the financial institutions involved in the processing of this electronic payment of taxes to
receive confidential information necessary to answer inquiries and resolve issues related to the payment.
NOTE: Your refund will be directly deposited to or your balance due will be electronically withdrawn from the bank account as shown
above. Please be sure these numbers are correct.
Please
Sign
Taxpayer's signature
Date
Spouse’s signature (if joint return, both must sign)
Date
Here
I do not want direct deposit of my refund or an electronic funds withdrawal (direct debit) of my balance due.
Part III
Declaration of Taxpayer
Under penalties of perjury, I declare that I have compared the information contained on my electronic return with the information that I provided to my electronic
return originator or entered on-line and that the name(s), address and amounts described above agree with the amounts shown on the corresponding lines of my
2001 Maryland electronic income tax return. To the best of my knowledge and belief, my return is true, correct and complete. I consent that my return, including
accompanying schedules and statements, be sent to the Maryland Revenue Administration Division by my electronic return originator or by my electronic return
software provider. If you did not use a PIN during the filing of this return, you must mail this declaration to the Revenue Administration Division to become part
of your return.
Please
Sign
Taxpayer's signature
Date
Spouse’s signature (if joint return, both must sign)
Date
Here
Please wait ten (10) days after the receipt of a valid acknowledgement before calling 410-260-7701 from Central
Maryland, or 1-800-218-8160 from elsewhere, about your refund.
Part IV
Declaration of Electronic Return Originator (paid preparer)
I declare that I have reviewed the taxpayer’s return and that the entries on this form are complete and correct to the best of my knowledge. I have
obtained the taxpayer’s signature before submitting the return to the Maryland Revenue Administration Division, have provided the taxpayer with a copy
of all forms and information to be filed with the Maryland Revenue Administration Division, and have followed all other requirements described in the
Handbook for Electronic Filers of Maryland Income Tax Returns (Tax Year 2001). This declaration is to be retained at the site of the electronic return
originator.
Date
EFIN
Originator’s
Electronic
signature
Return
Firm’s name (or yours
Originator
if self-employed)
Use Only
and address
ZIP code
Phone
COM/RAD-059