MARYLAND INCOME TAX
For fiscal year beginning
Name of corporation or pass-through entity
Federal employer identification number
Present address (number and street)
City or town
Tax Return Information (whole dollars only)
Amount of overpayment to be applied to 2013 estimated tax (Corporations only). . . . . . . . . . .
Amount of overpayment to be refunded (Corporations only) . . . . . . . . . . . . . . . . . . . . . . . . . .
Total amount due. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Check appropriate box to consent to:
Direct Deposit of refund or
Electronic Funds Withdrawal (direct debit)
4a. Type of account
4b. Routing number
4c. Account number
4d. Direct debit settlement date _______ / _____ / ______ (Enter the date you want the payment withdrawn from the account.)
4e. Direct debit amount _____________________
I consent that the corporation’s refund be directly deposited as designated above, and declare that the information shown is
correct. By consenting, I also agree to disclose to the Maryland State Treasurer’s Office certain income tax information including
name, amount of refund and the above bank information. This disclosure is necessary to effect direct deposit.
I authorize the State of Maryland and its designated financial agent to initiate an electronic funds withdrawal payment entry to
the financial institution account indicated for payment of the Maryland taxes owed by the corporation or pass-through entity and
the financial institution to debit the entry to this account. Upon confirmation of consent during the filing the corporation or pass-
through entity state return, this authorization is to remain in full force and effect, and I may not terminate the authorization. I
also authorize the financial institutions involved in the processing of this electronic payment of taxes to receive confidential
information necessary to answer inquiries and resolve issues related to the payment.
I do not want direct deposit of the refund or an electronic funds withdrawal (direct debit) of the balance due.
Under penalties of perjury, I declare that I am an officer, general partner or managing member of the above corporation or of the pass-
through entity. I have compared the information contained on my electronic return with the information that I provided to my electronic
return originator or entered on-line and that the name(s), address and amounts described above agree with the amounts shown on the
corresponding lines of my 2012 Maryland electronic income tax return. To the best of my knowledge and belief, the return is true, correct
and complete. I consent that the return, including accompanying schedules and statements, be sent to the Maryland Revenue Administration
Division by my electronic return originator or by the electronic return software provider.
Corporate officer, general partner or managing member’s signature
Please wait ten (10) days after the receipt of a valid acknowledgement before calling 410-260-7980 from Central
Maryland, or 1-800-638-2937 from elsewhere, about the refund.
Declaration of Electronic Return Originator (paid preparer)
I declare that I have reviewed the return of the corporation or pass-through entity and that the entries on this form are complete and
correct to the best of my knowledge. I have obtained the signature of the corporate officer, general partner or managing member, before
submitting the return to the Maryland Revenue Administration Division, have provided that official with a copy of all forms and information
to be filed with the Maryland Revenue Administration Division, and have followed all other requirements described in the Maryland Business
E-File Handbook. This declaration is to be retained at the site of the electronic return originator.
Firm’s name (or yours