Form Inc 250 - Individual Income Tax Return

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TENNESSEE DEPARTMENT OF REVENUE
INDIVIDUAL INCOME TAX RETURN
Beginning:
ACCOUNT NUMBER
Taxpayers filing on a calendar year basis must file their
INC
return by April 15 of the following year. Make your
Taxable
check payable to the Tennessee Department of Rev-
Year
Ending:
250
enue for the amount of tax computed and mail to:
Tennessee Department of Revenue
Andrew Jackson State Office Building
500 Deaderick Street
Nashville, TN 37242
(If filing jointly, include first names and initials of both spouses)
Should you need assistance, please contact the Taxpayer
Services Division by calling
(800) 342-1003 or (615) 253-0600
NAME
You may file your extension, return, and payment
through the Internet at
SPOUSE'S NAME
ADDRESS
}
If this is an AMENDED RETURN,
please check the box at right
ZIP
CITY
STATE
Because a portion of the tax goes back to the city or county of residence, please provide the county and city (if within
YOUR SSN:
an incorporated municipality) of the taxpayer’s legal residence on the lines below.
SPOUSE'S SSN:
County ________________________________________________________________
FEIN:
City __________________________________________________________________
AFFIDAVIT FOR EXEMPTION
For tax years beginning January 1, 2012, any person 65 years of age or older having a total annual income derived from any and all sources of $26,200 or less,
or any persons who file a joint return and either spouse is 65 years of age or older having a total annual joint income derived from any and all sources of not
more than $37,000 may qualify for a total exemption from income tax. IF YOU QUALIFY FOR THE EXEMPTION, DO NOT COMPLETE THE SCHEDULES BELOW.
CHECK THE BOX AT RIGHT AND SIGN RETURN ON THE BACK.
CHECK ALL BOXES THAT APPLY:
6.
Blind
9. Partnership
1.
Single
(yourself)
10. Limited
7.
Blind
4. Quadriplegic
2. Married Filing Jointly
Liability
(your spouse)
(yourself)
Entity
5.
Quadriplegic
3. Married Filing Separately
8. Trust
11. Estate
(your spouse)
(enter spouse's SSN # above)
WRITE NUMBERS LIKE THIS
ROUND TO THE NEAREST DOLLAR
TAX COMPUTATION
00
1. GROSS TAXABLE INCOME (From Schedule A) .................................................................. (1)
{
$1,250 if single or married filing separately
00
2. SUBTRACT EXEMPTION
............................. (2)
$2,500 if married filing jointly
00
3. AMOUNT SUBJECT TO TAX (Line 1 less Line 2) .......................
(3)
00
4. INCOME TAX (6% of Line 3) .......................................................
(4)
00
5. ENTER: Amount paid with extension request and/or prepayment(s) ................................ (5)
If filed late, compute penalty at 5% of the tax (Line 4 minus Line 5) for each 1 to 30 DAY PERIOD
{
00
for which TAX IS DELINQUENT (Total penalty NOT TO EXCEED 25%.) Minimum penalty is $15
6. PENALTY
................ (6)
regardless of the amount of tax due or whether there is any tax due
{
00
If filed late, compute interest at
% per annum on the tax (Line 4 minus
7. INTEREST
................................... (7)
Line 5) from the due date of payment to the date paid
00
8. TOTAL AMOUNT DUE (Add Lines 4, 6, and 7; subtract Line 5) ......................................... (8)
00
9. REFUND (If Line 5 exceeds total of Lines 4, 6, and 7, enter overpayment here) .............. (9)
FOR OFFICE
USE ONLY
(INTERNET 1-13)
RV-R0003501

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