For Office Use Only
2001
538-s
Oklahoma Claim for Credit or Refund of Sales Tax
Your Social Security Number
Instructions on reverse side.
Please read carefully as an incomplete form
Spouse’s Social Security Number
may delay your refund.
Print first name, initial and last name (first name and initial of spouse)
Part 1: Taxpayer Information
Check if you or your spouse have a physical disability
constituting a substantial handicap to employment
Present home address (number and street, including apartment number, or rural route)
(submit proof)
Check if you or your spouse are 65 years of age or over
City, State and Zip
Date lived in Oklahoma: from __________ to _________
Oklahoma resident for the full year?
yes
no
Part 2: Dependent and Exemption Information
See Instructions
1. Dependents
Qualified Exemptions...
5. Yearly
(first name, initial, last name)
2. Age 3. Social Security Number
4. Relationship
Income
A. Yourself ............................
B. Spouse ............................
C. Number of your
dependent children ..
D. Number of other
dependents .............
E. Total exemptions
claimed (add A, B,
C, and D) .................
Part 3: Gross Income
(Round to Nearest Dollar)
Enter gross income and assistance, taxable and nontaxable, received by ALL members of your household in the year 2001.
You may not enter negative amounts.
Yearly Income
1.
Enter total wages, salaries, fees, commissions, bonuses, and tips
1
00
(including nontaxable income from your W-2) ...................................................................
2
00
2.
Enter total interest and dividend income received ............................................................
3
00
3.
Total of all dependents' income (from Part 2, column 5) ....................................................
4
00
4.
Social Security payments (total including Medicare) .........................................................
5
00
5.
Railroad Retirement benefits .............................................................................................
6
00
6.
Other pensions, annuities and IRAs ..................................................................................
7
00
7.
Alimony .............................................................................................................................
8
00
8.
Unemployment benefits ....................................................................................................
9
00
9.
2000 Earned Income Credit (EIC) received in 2001 and Advanced EIC received in 2001
10
00
10.
Nontaxable sources of income (specify) ________________________________ .........
11.
Enter gross income from rental, royalties, partnerships, estates and trusts, and gains
11
00
from the sale or exchange of property (taxable & nontaxable) (enclose Federal return including schedules) .
12
00
12.
Enter gross business and farm income (enclose Federal return including schedules) .................
13
00
13.
Other (specify) _____________________________________ .....................................
14
00
14.
Total gross household income (Add lines 1-13) ...............................................................
If line 14 is over limits shown in steps 3 and 4 on back of form, no credit is allowed.
Part 4: Sales Tax Credit Computation
(For households with gross income below allowable limits. See steps 3 and 4 on back of form.)
00
15.
Total qualified exemptions claimed in Box E above
x $40 (credit claimed)
15
Once you have completed this form, please refer to the back of the form for “Filing instructions and due date.”
If you are filing a Form 511, carry the amount on line 15 to the Form 511, line 28.
Under penalty of perjury, I declare that the information contained in this document and any attachments is true and correct to the best of my knowledge and belief.
Taxpayer’s Signature and Date
Spouse’s Signature and Date
Occupation(s)