Form 481.0 - Individual Income Tax Return - 2004 (Page 3 of 3) in pdf

Social Security Number

Form 481.0, Rev. 05.04 - Page 3

Taxpayer's name ________________________________________________

Part 4

TAX DETERMINED (Determine your tax on the amount of line 10 using the Tax Table) .........................................................

11.

(30)

Credit for Salaried Taxpayers (See instructions) ..............................................................................................

12.

(31)

Credit for Salaried Persons or Pensioners (See instructions) ...........................................................................

13.

(32)

Credit for Contributions to the Educational Foundation for Free Selection of Schools .......................................

14.

(33)

Tax Liability (Subtract line 12, 13 or 14, whichever applies, from line 11. If it is less than zero, enter zero) ....................

15.

(34)

TAX WITHHELD:

16.

A) Tax Withheld on Wages (Add lines 1A and 2A of Part 2) ............................................

(35)

B) Tax Withheld on Annuities and Pensions (Schedule H Individual, Part II, line 13) .............

(36)

C) Total Tax Withheld (Add lines 16A and 16B) ...............................................................................................................

(37)

AMOUNT OF TAX DUE (If line 15 is larger than line 16C, enter the difference here,

17.

otherwise, enter on line 22) ..............................................................................................................................................

(38)

Less: Amount paid with automatic extension of time .......................................................................................................

18.

(39)

Balance of Tax Due (If line 17 is larger than line 18, enter the difference here, otherwise, enter on line 22) ..........................

19.

(40)

Less: Amount paid

(a)

20.

With Return or Electronic Transfer through Tax Returns Online .............................................................................

(41)

(b)

Other Electronic Transfers ................................

Transaction Number:

(42)

(c)

Interest .............................................................................................................

(43)

(d)

Surcharges __________ and Penalties __________ ................................

(44)

BALANCE OF TAX DUE (Subtract line 20(a) and 20(b) from line 19) .............................................................................

21.

(45)

AMOUNT TO BE REFUNDED (If you want your refund to be deposited directly to an account, complete Part 5) ..

22.

(50)

Part 5

AUTORIZATION FOR DIRECT DEPOSIT OF REFUND

Route/transit number

Your account number

Type of account:

Checks

Savings

and

Account in the name of

(Complete name in print letter as it appears on your account. If married and filing jointly, include your spouse's name)

OATH

I hereby declare under penalty of perjury that this return (including the statements, schedules and other documents attached) has been examined by

me and to the best of my knowledge and belief is a true, correct and complete return. I also declare that I have provided more than 50% of the support

for all dependents claimed. The declaration of the person that prepares this return (except the taxpayer) is with respect to the information received, and

this information has been verified.

Taxpayer's Signature

Date

Spouse's Signature

Date

Specialist's Name (Print Letter)

Name of the Firm or Business

Address

Registration Number

Employer's Identification Number

Date

Specialist's Signature