Form 200-03 Ez - Delaware Individual Resident Income Tax Return - 2004

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DO NOT WRITE OR STAPLE IN THIS AREA
DELAWARE INDIVIDUAL RESIDENT
EZ
2004
INCOME TAX RETURN
FORM 200-03 EZ
or Fiscal year beginning
and ending
Your Social Security No.
Spouse’s Social Security No.
(Attach Label Here) DO NOT COVER SOCIAL SECURITY NUMBERS
Your Last Name
First Name and Middle Initial
Jr., Sr., III., etc.
Spouse’s Last Name
Spouse’s First Name
Jr., Sr., III., etc.
Present Home Address (Number and Street)
Apt. #
City
State
Zip Code
FILING STATUS (MUST CHECK ONE)
If you were a part-year resident in 2004, give the dates you resided in Delaware.
1.
Single, Divorced,
2.
Joint
5.
Head of
From
2004
To
2004
Widow(er)
Household
Month
Day
Month
Day
CHECK IF: YOU WERE 65 OR OVER
BLIND
CHECK IF: SPOUSE WAS 65 OR OVER
BLIND
00
1
1.
ENTER AMOUNT FROM FEDERAL RETURN (See instructions on back)...............................................................
00
2
2.
Pension/Retirement Exclusion (See instructions on back).........................................................................................
00
3.
Delaware Adjusted Gross Income. Subtract Line 2 from Line 1..............................................................................
3
4.
Standard Deduction:
Filing Statuses 1 & 5 Enter $3250
Filing Status 2 Enter $6500............................................................................................
4
00
5.
ADDITIONAL STANDARD DEDUCTION FROM WORKSHEET (See back)..............................................................
5
00
6.
Add Lines 4 and 5.....................................................................................................................................................
6
00
7.
Subtract Line 6 from Line 3. This is your TAXABLE INCOME
00
7
Compute Tax on this Amount or Use the Tax Table....................................................................................................
00
8.
Tax Liability from Tax Table/Schedule........................................................................................................................
8
00
9a. Enter number of exemptions claimed on Federal Return.
X $110..........................................................
9a
9b. CHECK BOX(ES):
If you were 60 or over
Spouse was 60 or over (Filing Status 2)
00
Enter number of boxes checked
X $110.............................................................................................
9b
00
10
10. Tax imposed by State of
(Must attach a signed copy of return)...............................................
00
11
11.
TOTAL Non-Refundable Credits. Add Lines 9a, 9b & 10 and enter here...................................................................
00
12. BALANCE. Subtract Line 11 from Line 8 and enter here. If Line 11 is greater than Line 8, enter “0” (ZERO)...........
12
13
00
13. Delaware Tax Withheld (W-2s/1099s required)........................................................................................................
14
14. 2004 Estimated Tax and Extension Payments...........................................................................................................
00
15
15. TOTAL Refundable Credits. Add Lines 13 and 14 and enter here .............................................................................
00
16
16. BALANCE DUE. If Line 12 is greater than Line 15, subtract Line 15 from Line 12 and enter here..........................>
00
17
17. OVERPAYMENT. If Line 15 is greater than Line 12, subtract Line 12 from Line 15 and enter here.........................>
00
00
18.
CONTRIBUTIONS TO SPECIAL FUNDS
E.
Breast Cancer Educ.
00
00
A.
Non-Game Wildlife
F.
Organ Donations
00
00
G. Diabetes Educ.
B.
U.S. Olympics
00
00
C.
Emergency Housing
H.
Veteran’s Home
00
00
18
00
D.
Children’s Trust
I.
DE National Guard
TOTAL>
00
19
19.
AMOUNT OF LINE 17 TO BE APPLIED TO 2005 ESTIMATED TAX ACCOUNT.......................................ENTER >
00
20
20.
PENALTIES AND INTEREST DUE. If Line 16 is greater than $400, see estimated tax instructions.......ENTER>
00
21
21.
NET BALANCE DUE. Add Lines 16, 18 and 20 and enter here.....................................................PAY IN FULL>
00
22
22.
NET REFUND. Subtract Lines 18, 19 and 20 from Line 17...............................ZERO DUE/TO BE REFUNDED>
DIRECT DEPOSIT INFORMATION
If you would like your refund deposited directly to your checking
or savings account, complete boxes a, b and c below. See instructions for details.
DATE OF DEATH
a. Routing Number
b. Type:
Checking
Savings
SPOUSE
TAXPAYER
/
/
/
/
c. Account Number
Month
Day
Year
Month
Day
Year
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and believe it is true, correct and complete.
Your Signature
Date
Signature of Paid Preparer
Date
Spouse’s Signature (If filing joint)
Date
Address-Zip Code
Home Phone
Business Phone
Business Phone
EIN, SSN, OR PTIN
E-Mail Address
E-Mail Address

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