Webfile Worksheet Form - Iowa Department Of Revenue And Finance

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IOWA
IOWA
department of Revenue and Finance
DEPARTMENT
2001
WebFile
Worksheet
OF
and
09/27/01 41-143
Complete this worksheet and then go to: to file your return
Year of Birth
Confirmation #
Your Social Security Number
Spouse’s Social Security Number
4-digit PIN
Date Filed
Marital status: Single
Married
If single, were you claimed as a dependent on another person’s Iowa income tax return? yes
no
Enter the total number of dependents you are claiming on this return:
NOTE: Tax information must be separately reported between taxpayer and spouse
Employer
Wages, including tips
Federal
Iowa
ID Number
(Wages - Box 16)
Tax Withheld
Tax Withheld
(Box 2)
(Box 17)
(9 digits - Box b)
(Tips - Box 8)
1st W-2
$
Enter the total
2nd W-2
$
number of
Taxpayer W-2 forms
3rd W-2
$
for 2001
4th W-2
$
5th W-2
$
1st W-2
$
Enter the total
2nd W-2
$
number of
3rd W-2
$
Spouse W-2 forms
for 2001
$
4th W-2
$
5th W-2
Federal Tax Withheld
Income
Iowa Tax Withheld
Spouse
Taxpayer
Spouse
Taxpayer
Spouse
Taxpayer
Unemployment compensation $
$
$
Spouse Taxpayer
Total taxable interest income $
Direct Deposit Information
Routing Transit Number:
Total ordinary dividend income $
Federal income tax refund, received in 2001 $
Type of Account Depositing to:
Additional Federal tax paid in 2001 for 2000 and any prior years $
Checking
Savings
2001 Federal earned income credit $
Depositor Account Number:
Itemized Deductions (Do not divide between spouses)
Other state and local income taxes $
Real estate taxes $
Iowa Election Campaign Fund
Personal property taxes $
$1.50 to Democratic Party
$1.50 to Republican Party
Other taxes $
$1.50 to Green Party
Home mortgage interest and points on Federal form 1098 $
$1.50 to Campaign Fund
Home mortgage interest not reported on Federal form 1098 $
$1.50 to Democratic Party
Points not reported on Federal 1098 $
$1.50 to Republican Party
Contributions by cash/check $
$1.50 to Green Party
$1.50 to Campaign Fund
Contributions other than cash/check, less than $500 $
Fish and Wildlife Fund $
Keep Iowa Beautiful Fund $
State Fairgrounds Renovation $
DO NOT MAIL - Retain For Your Records
Are you paying additional tax?
Mail your return and payment to Iowa Income Tax - Document Processing, PO Box 9187, Des Moines IA 50306-9187

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