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2012 FORM MO-1040A

MISSOURI DEPARTMENT OF REVENUE

INDIVIDUAL INCOME TAX RETURN

SINGLE/MARRIED ( ONE INCOME )

VENDOR CODE

SOCIAL SECURITY NUMBER

SPOUSE’S SOCIAL SECURITY NUMBER

NAME (LAST)

(FIRST)

M.I. JR, SR

SPOUSE’S (LAST)

(FIRST)

M.I. JR, SR

IN CARE OF NAME (ATTORNEY, EXECUTOR, PERSONAL REP., ETC.)

PRESENT ADDRESS (INCLUDE APARTMENT NO. OR RURAL ROUTE)

COUNTY OF RESIDENCE

CITY, TOWN, OR POST OFFICE

STATE

ZIP CODE

PLEASE CHECK THE APPROPRIATE BOXES THAT APPLY TO YOURSELF OR YOUR SPOUSE.

AGE 65 OR OLDER

BLIND

100% DISABLED

NON-OBLIGATED SPOUSE

YOURSELF

SPOUSE

1. Federal adjusted gross income from your 2012 federal return. (See page 6 of the instructions.). .................................

–

2. Any state income tax refund included in your 2012 federal adjusted gross income. . ...........................................

3. Total Missouri adjusted gross income — Subtract Line 2 from Line 1. .................................................................

4. M ark your filing status box below and enter the appropriate exemption amount on Line 4.

A. Single — $2,100 (See Box B before checking.)

D. Married filing separate — $2,100

B. C laimed as a dependent on another person’s federal

E. Married filing separate (spouse

tax return — $0.00

NOT filing) — $4,200

C. M arried filing joint federal & combined Missouri — $4,200

F. Head of household — $3,500

G. Q ualifying widow(er) with

Check which spouse had income:

Yourself

Spouse

dependent child — $3,500

5. Tax from federal return (Do not

Enter this amount on Line 5 or $5,000, whichever is less.

enter federal income tax withheld.) —

If married filing combined, enter this amount on Line 5

or $10,000, whichever is less.

6. Missouri standard deduction or itemized deductions. Single or Married Filing Separate— $5,950; Head of

Household — $8,700; Married Filing a Combined Return or Qualifying Widow(er) — $11,900. If you are age 65 or

older, blind, or claimed as a dependent, see your federal return or page 7. If you are itemizing, see back of form.

Federal Form 1040 OR 1040A, Line 6c

7. Number of dependents you claimed on your

(Do not include yourself or your spouse.) ...........................................................

x $1,200 = ..............

8. Long-term care insurance deduction . .....................................................................................................................

9. Total Deductions — Add Lines 4 through 8. . ..........................................................................................................

10. Missouri Taxable Income — Subtract Line 9 from Line 3. . .....................................................................................

11. Tax — Use the tax table on the back of this form to figure the tax. . .......................................................................

12. Missouri tax withheld from your Forms W-2 and Forms 1099. Attach copies of Forms W-2 and Forms 1099. ....

13. Any Missouri estimated tax payments made for 2012 (include overpayment from 2011 applied to 2012) ............

14. Total Payments — Add Lines 12 and 13. . ..............................................................................................................

15. If Line 14 (Total Payments) is more than Line 11 (Total Tax), enter the difference (amount of overpayment)

here. (If Line 14 is less than Line 11, skip to Line 19.) ..........................................................................................

16. Amount from Line 15 that you want applied to your 2013 estimated tax .............................................................

17. Enter the amount

Additional

LEAD

of your donation in

eneral

Workers

Missouri

Fund Code

evenue

the trust fund boxes

National

Military

(See Instr.)

Childhood Lead

Workers’

Elderly Home

After School

Children’s

Veterans

General

Missouri

to the right. See the

Family Relief

Guard

Testing Fund

Memorial Fund

Delivered Meals

Trust Fund

Retreat Fund

______|______

Trust Fund

Revenue Fund

Organ Donor

Trust Fund

Fund

instructions for fund

Trust Fund

Program Fund

codes.................. 17.

1 8. REFUND - Subtract Lines 16 and 17 from Line 15 and enter here. This is your refund. Sign below and mail to:

Department of Revenue, P.O. Box 500, Jefferson City, MO 65106-0500.

Check the box if you want your refund issued on a debit card. See instructions for Line 18. .........

Debit Card

If you would like your refund deposited directly to your checking or savings account, complete boxes a, b, and c below.

a. Routing Number

b. Account Number

Checking

Savings

19. AMOUNT DUE - If Line 14 is less than Line 11, enter the difference here. You have an amount due. Sign below and

mail to: Department of Revenue, P.O. Box 329, Jefferson City, MO 65107-0329. See instructions for Line 19. .......

If you pay by check, you authorize the Department of Revenue to process the check electronically. Any check returned unpaid may be presented again electronically.

Under penalties of perjury, 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. Declaration of

preparer (other than taxpayer) is based on all information of which he or she has any knowledge. As provided in Chapter 143, RSMo, a penalty of up to $500 shall be imposed on any individual who files a frivolous

return. I also declare under penalties of perjury that I employ no illegal or unauthorized aliens as defined under federal law and that I am not eligible for any tax exemption, credit or abatement if I employ such aliens.

I authorize the Director of Revenue or delegate to discuss my return and

E-MAIL ADDRESS

PREPARER’S PHONE

attachments with the preparer or any member of the preparer’s firm.

(__ __ __) __ __ __ - __ __ __ __

YES

SIGNATURE

DATE

PREPARER’S SIGNATURE

FEIN, SSN, OR PTIN

__ __/__ __/__ __ __ __

SPOUSE’S SIGNATURE (If filing combined, BOTH must sign)