Tax And Rent Refund Application - Maine Revenue Services

2004

Tax and Rent Refund Application

(page 2)

*0403701*

6. ANNUAL HOUSEHOLD INCOME FOR 2003 (Total amount for Applicant, Spouse, and Dependents)

a. Maine adjusted gross income (total for all household members. See instructions) .................. 6a.$

Note: If you have not filed a 2003 Maine income tax return, leave this line blank and

go to line 6b.

b. Additional income (from schedule below) ............................................................................. 6b.$

c. Add line a and line b .................................................................................................................. 6c.$

d. Rollovers of IRA, pension, or annuities and Property Tax Program Refunds if included on line 6a .. 6d.$

(Read instructions on pages 5 and 6 before entering an amount on this line.)

e. Total household income (subtract line 6d from line 6c) ............................................................ 6e.$

Column 1

Column 2

SCHEDULE OF ADDITIONAL INCOME

For those who filed a

For those who did not

(for line 6b above)

2003 Maine Income

file a 2003 Maine

Additional Annual Income (Write in yearly income amounts).

Tax Return

Income Tax Return

a. Total Salaries,

Wages*

.............................................................. a.

___________________

a. $ ___________________

b. Dividends, Interest - all sources ................................................ b.

___________________

b. $ ___________________

c. Loss Add-Back (see instructions on page 5) ............................ c. $ ___________________

___________________

d. Social Security, Railroad Retirement, Pensions, Pension

Income Deduction, Annuities, Veterans Compensations .......... d. $ ___________________

d. $ ___________________

e. Cash Public Assistance, TANF ................................................. e. $ ___________________

e. $ ___________________

f. State Supplemental Income (This is not social

security income) ....................................................................... f. $ ___________________

f. $ ___________________

g. Any other Income (see page 6 for types of income to list) ..... g. $ ___________________

g. $ ___________________

h. Total (add lines a through g) ..................................................... h. $ ___________________

h. $ ___________________

(Enter total from line h, either column 1 or column 2, on line 6b above.)

*Enter the total amount of money earned. This is the amount before taxes or other deductions are subtracted.

7. Direct Deposit Information — If you want your refund sent directly to your bank account, see instructions on page 6 and fill in the

blocks below. NOTE: Completing the information below authorizes Maine Revenue Services to disclose your social security number,

listed on the front of this form, to your financial institution for the sole purpose of depositing your refund directly into your bank account.

7a. Routing

7b. Account

7c. Type of

Checking

Number:

Account:

Savings

8. Third Party Designee (see instructions on page 6): Do you want to

allow another person to discuss this return with Maine Revenue Services? ............

Yes (complete the following).

No.

Designee’s

Phone

5-digit Personal identification

name: ______________________________________

number: __________________________ number:

Under penalty of perjury, I declare that I have examined this application and to the best of my knowledge and belief, it is true, correct, and complete.

Applications may be audited either before or after refunds are issued. Refunds may be applied to other outstanding government debts you may owe.

Signature of Applicant

Date

Signature of Preparer other than Applicant

Date

If you Telefile your application, you will receive a 9-digit confirmation number after you have successfully completed the application

process. You must write this number below and keep this application for your records. It is proof that you filed an application.

CONFIRMATION NUMBER:

NOTE: If you do not Telefile, leave this information blank and mail this application to Maine Revenue Services in the envelope provided.

Mail your application in the envelope provided.

Office Use only:

Maine Revenue Services, PO Box 9116, Augusta, ME 04332-9116

Tax And Rent Refund Application - Maine Revenue Services - 2004 Page 2

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