200
2017
LOCAL INTANGIBLES TAX RETURN
(Rev. 9-16)
For tax year January 1 - December 31, 2016, or other taxable year beginning ______________ , 20 ____ ; ending _____________ , 20_______
First Name (If joint return, use first names and middle initials of both)
Last Name
Your Social Security Number
Spouse’s Social Security Number
Mailing Address (Number and street, including apartment number, or rural route)
Federal Identification Number
City, Town, or Post Office, State and Zip Code
For County Use Only
Ques
tions 1 & 2 must be answered before your intangibles tax rate can be determined.
TAX UNIT NUMBER
1.
Is your legal residence located within the corporate limits of a city or town?
o
Yes. If yes, name of city or town:__________________________________________________
o
No. If no, name of township:
____________________________________________________
2.
County of residence as of January 1, 2017: ______________________________________________
3.
Intangibles income (from line 11, Part 1 or line 17, Part II)
$ ____________________________
YOUR COUNTY CLERK WILL COMPUTE YOUR INTANGIBLES TAX LIABILITY. YOUR COUNTY TREASURER WILL BILL YOU.
DO NOT SEND ANY PAYMENT FOR INTANGIBLES TAX TO THE KANSAS DEPARTMENT OF REVENUE.
PART I – INTANGIBLES EARNINGS
4. Interest from bank savings accounts, certificates of deposit, other time deposits, insurance companies, and interest
or dividends received from all savings and loan associations and credit unions...........................................................
4
5. Dividends or other income from corporation stock including those located in Kansas and dividends or interest
income received from mutual funds and trust companies..............................................................................................
5
6. Interest from notes (except when secured by mortgages on Kansas real estate when registration fee has been paid)
6
7. Earnings from conditional sales contracts, chattel paper, or other secured transactions ..............................................
7
8. Interest or discount income from bonds, debentures, and certificates of indebtedness ................................................
8
9. Interest carrying charges and other income from accounts receivable (nonresidents: see instructions) ......................
9
10. Other intangibles income (see instructions)...................................................................................................................
10
11. Total intangibles income. If you qualify for the “Special Senior Citizen or Disability Exemption” complete Part II
to determine your intangibles income. If you do not qualify for the exemption, enter this amount on line 3. ..............
11
PART II – SPECIAL SENIOR CITIZEN OR DISABILITY EXEMPTION – see instructions
(Part II must be completed entirely or the exemption will not be allowed)
MONTH
DAY
YEAR
12. Your date of birth.
If
you
were
born
after
January
1,
1957 ,
you
must
be
blind
or
disabled to qualify (see instructions)......................................................................................
o
o
13. Is this special exemption based on disability or blindness? If yes, attach proof of disability or blindness (see instructions).
Yes
No
14. Total household income for 2016 (must be less than $20,000; see instructions)..........................................................
14
15. Enter total intangibles income from Part I, line 11 .........................................................................................................
15
16. LESS: Special intangibles income exemption (see instructions for allowable exemption) ............................................
16
17. Taxable intangibles income (subtract line 16 from line 15; enter result here and on line 3 above) ...........................
17
I declare under the penalties of perjury that to the best of my knowledge and belief, this is a true, correct, and complete return.
___________________________________________________________
_______________________________________________
sign
Signature of taxpayer
Date
here
___________________________________________________________
_______________________________________________
If joint return, BOTH husband and wife must sign
Signature of preparer if other than taxpayer
YOUR TELEPHONE NUMBER_____________________________________
TELEPHONE NUMBER – The number you furnish will be confidential
and should be the one we can reach you at during office hours.
MAIL THIS RETURN TO YOUR LOCAL COUNTY CLERK’S OFFICE (addresses available with the tax rates).
DO NOT send this return or payment for Intangibles Tax to the Kansas Department of Revenue.