Form Ia 8453 - Iowa Individual Income Tax Declaration For Electronic Filing

IRS Declaration Control Number (DCN)

IOWA

IA 8453 2000

d e p a r t m e n t o f R ev e n u e a n d F i n a n c e

0 0

Iowa Individual Income Tax

For the year January 1 - December 31, 2000

Declaration for Electronic Filing

See Instructions on Back

Your first name, middle initial

Last name

Your Social Security Number

Please Print

Spouse’s first name, middle initial

Last name

Spouse’s Social Security Number

or Type

Current mailing address (number and street) or PO Box

Daytime Telephone Number

Apt., Suite, Lot, RR, etc. (or street address if delivery is to a PO Box)

City, town or post office, state and ZIP code

Part I. Tax Return Information

(whole dollars only)

B. Spouse - filing

A. You or Joint

status 3 only

1. Iowa Net Income (IA 1040 line 26 A & B or IA 1040A line 4) ................................. 1B ________ .00 1A _________ .00

2. Total Iowa Tax before credits (IA 1040 line 46 A & B or IA 1040A line 9) ............ 2B ________ .00 2A _________ .00

3. Iowa Income Tax Withheld (IA 1040 line 61 A & B or IA 1040A line 19) ............... 3B ________ .00 3A _________ .00

4. Amount to be Refunded (IA 1040 line 70 or IA 1040A line 20) .............................................................. 4 __________ .00

5. Amount Due (IA 1040 line 75 or IA 1040A line 24) .................................................................................. 5 __________ .00

Part II. Direct Deposit of Refund (Optional - See instructions.)

6. Name of financial Institution and, if applicable, branch name ______________________________________________

7. Routing Transit Number (RTN)

The first two numbers of the RTN must be 01 through 12 or 21 through 32.

8. Depositor Account Number (DAN)

9. Type of Depositor Account:

Savings

Checking

Part III. Taxpayer Declaration

Under penalties of perjury, I declare that the information I have provided to my Electronic Return Originator (ERO) and the amounts shown in Part I

above agree with the amounts shown on the corresponding lines of the electronic portion of my 2000 Iowa income tax return. To the best of my

knowledge and belief my return is true, correct and complete. I consent that my return, including any accompanying schedules and statements, be sent

to the Internal Revenue Service (IRS) by my ERO and retrieved by the Iowa Department of Revenue and Finance (IDRF). If I have filed a balance due

return, I understand that if the IDRF does not receive full and timely payment of my tax liability I will remain liable for the tax liability and all applicable

interest and penalties. I consent that my refund be directly deposited as designated in Part II and declare that the information shown on lines 7 through

9 is correct. If I have filed a joint or combined state return and elected direct deposit, there is an irrevocable appointment of the other spouse to receive

the refund. If there is an error on my federal return, I understand my state return will be rejected. If the processing of my return or refund is delayed, I

authorize the IDRF to disclose to my ERO and/or transmitter the reason(s) for the delay or when the refund was sent. I also consent to the IDRF

sending to my ERO and/or transmitter an acknowledgement of receipt of transmission and indication of whether or not my return is accepted, and, if

rejected the reason(s) for the rejection. I understand that this declaration with required attachments must be forwarded upon request to the IDRF as

validation of my electronically filed Iowa individual income tax return.

Sign

Here

Your Signature

Date

Spouse’s Signature

Date

Part IV. Declaration of Electronic Return Originator (ERO) and Paid Preparer (See instructions.)

I declare that I have reviewed the above taxpayer’s return and that entries on form IA 8453 are complete and correct to the best of my knowledge. If I

am only a collector, I am not responsible for reviewing the return and only declare that this form accurately reflects the data on the return. I have

obtained the taxpayer’s signature on form IA 8453 before submitting this return to the IRS, have provided the taxpayer with a copy of all forms and

information to be filed with the IDRF, and have followed all other requirements described in the Iowa Federal/State Electronic Filing Handbook, Tax

Year 2000. I will keep form IA 8453, with attachments, on file for three years from the due date of the return or the filing date, whichever is later

and I will make a copy available to IDRF upon request. If I am a paid preparer under penalties of perjury, I declare that I have examined the above

taxpayer’s return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and complete.

This declaration is based on all information of which I have any knowledge.

ERO

ERO’s

Date

Check if

Check