Form 502b - Maryland Dependents' Information - 2012 Page 2
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1
2Maryland Dependents' Information
FORM
Page 2
502B
(Attach to Form 502, 505 or 515)
2012
NAME _______________________________________ SSN ___________________
Dependents
1.
Initial
Last name
First name
2.
3.
Social Security number
Relationship
4.
if under 19
5. Has medical insurance?
Yes
No
6.
Regular
7.
65 or over
(For Form 502, resident taxpayers only)
1.
Initial
Last name
First name
2.
3.
Social Security number
Relationship
4.
if under 19
5. Has medical insurance?
Yes
No
6.
Regular
7.
65 or over
(For Form 502, resident taxpayers only)
1.
Initial
Last name
First name
2.
3.
Social Security number
Relationship
4.
if under 19
5. Has medical insurance?
Yes
No
6.
Regular
7.
65 or over
(For Form 502, resident taxpayers only)
1.
Initial
Last name
First name
2.
3.
Social Security number
Relationship
4.
if under 19
5. Has medical insurance?
Yes
No
6.
Regular
7.
65 or over
(For Form 502, resident taxpayers only)
1.
Initial
Last name
First name
2.
3.
Social Security number
Relationship
4.
if under 19
5. Has medical insurance?
Yes
No
6.
Regular
7.
65 or over
(For Form 502, resident taxpayers only)
COM/RAD-026
12-49
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