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Form Ar8453-Ol - Arkansas Individual Income Tax Declaration For On-Line Electronic Filing - 2004

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Office Use Only - Do Not Write or Staple in This Space

2004

AR8453-OL

Arkansas Individual Income Tax Declaration

for On-Line Electronic Filing

For the tax year January 1 - December 31, 2004

Last Name(s)

Your Social Security #

First Name and Initial

USE

STATE

Spouse’s Social Security #

Present Address

LABEL

Telephone Number

City, Town or Post Office Box, State and Zip Code

PART 1

TAX RETURN INFORMATION (Whole Dollars Only)

1. Total Income (Form AR1000 or AR1000NR, Line 22) .............................................

2. Net Tax (Form AR1000 or AR1000NR, Line 52) ......................................................

3. State Income Tax Withheld (Form AR1000 or AR1000NR, Line 53) ........................

4. Refund (Form AR1000 or AR1000NR, Line 58) .......................................................

5. Tax Due (Form AR1000 or AR1000NR, Line 62) .....................................................

PART 2

DECLARATION OF TAXPAYER

6a.

I consent that my refund be directly deposited as designated in the electronic portion of my 2004 Arkansas income

tax return. If I have filed a joint return, this is an irrevocable appointment of the other spouse as an agent to receive

the refund.

I do not want direct deposit of my refund or I am not receiving a refund.

If I have filed a balance due return, I understand that if the state of Arkansas 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. If I have filed a joint Federal and state

return and my federal return is rejected, I understand my state return will be rejected also.

Under the penalties of perjury, I declare that the information I have provided and the amounts in Part I above agree with

the amounts on the corresponding lines of the electronic portion of my 2004 Arkansas income tax return. To the best of my

knowledge and belief, my return is true, correct, and complete.

Sign

Here

Your Signature

Date

Spouse’s Signature

Date

Please mail AR8453-OL to:

Electronic Return Group

P. O. Box 8067

Little Rock, AR 72203-8067

AR8453-OL (Rev 10/04)

Form Ar8453-Ol - Arkansas Individual Income Tax Declaration For On-Line Electronic Filing - 2004

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