Form Sf-1040 - Individual Return - 2004 Page 2
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3EXEMPTIONS & DEPENDENTS SCHEDULE
Perm. Disabled
Regular
65 & over
Blind
Deaf
Date of Birth
Para-/Hemi-/
Quadriplegic
You
Box A - Number of
Box A
boxes checked
Spouse
First Name
Last Name
Social Security Number
Relationship
Date of Birth
Box B - Number of
Box B
dependents you
claimed on your
federal return
(list to the left)
Box C -Total
Box C
Exemptions.
0
(Box A and B)
SCHEDULE SF-W2 - FOR FORM SF-1040 LINE 1
Total wages
Check here if for Spouse
Total wages
Check here if for Spouse
EMPLOYER 1
EMPLOYER 3
( W-2, box 1)
(W-2, box 1)
Employer's
Employer's
name
name
Address of actual
Address of actual
work station
work station
Dates of
From
To
Dates of
From
To
employment
employment
Check here if for Spouse
Check here if for Spouse
EMPLOYER 2
EMPLOYER 4
Employer's
Employer's
name
name
Address of actual
Address of actual
work station
work station
Dates of
From
To
Dates of
From
To
employment
employment
DIRECT DEPOSIT OF REFUND
A.
Check box for direct deposit of refund. List bank account information below.
B. Routing number
C. Account number
D. Type of account:
Checking
Savings
YOU MAY PAY BY ONE OF THE FOLLOWING METHODS
Total $
Card Number:
Exp. Date:
/
Signature:
Month
Year
THIRD PARTY DESIGNEE
Do you want to allow another person to discuss this return with the Income Tax Department?
Yes
No
If yes, complete the following:
Designee's
Phone
Personal identification
name
No.
number (PIN)
PLEASE SIGN YOUR RETURN BELOW
If Joint return, both husband and wife must sign.
I declare that I have examined this return (including accompanying schedules and statements) and to the best of my knowledge and belief it is true, correct and complete.
If prepared by a person other than taxpayer, the preparer's delaration is based on all information of which he/she has any knowledge.
====>
Date:
Date
:
X
X
TAXPAYER'S SIGNATURE
SIGNATURE OF PREPARER OTHER THAN TAXPAYER
SIGN
HERE
Occupation:
Phone #
====>
Date:
PREPARER'S ADDRESS
X
SPOUSE'S SIGNATURE
Occupation
PREPARERS PHONE NUMBER:
MAKE CHECK OR MONEY ORDER PAYABLE TO
:
CITY TREASURER
MAIL TO: CITY INCOME TAX DEPARTMENT, 601 AVENUE A, SPRINGFIELD, MI 49015-1499
Check this box if someone else prepares your return and you DO NOT need a booklet mailed to you next year
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