School District Surcharge Refund Claim printable pdf download

School District Surcharge Refund Claim

SCHOOL DISTRICT SURCHARGE REFUND CLAIM

This claim for refund is for the 10% income tax surcharge levied in certain school districts during

calendar year 1996. In order to complete this claim, you may need to refer to your 1996 Arkansas

Individual Tax Return.

PART I: Filing Status . What was your tax return filing status for tax year 1996? (check one)

1. _____ Single

2. _____ Married Filing Joint Return

3. _____ Head of Household

4. _____ Married Filing Separately on Same Return

5. _____ Married Filing Separately on Different Returns

6. _____ Qualifying Widower

PART II. Single Filers . If you checked lines 1, 3, 5, or 6, complete lines 7, 8, 11, and 12 only.

PART III: Joint Filers . If you are still married to the spouse with whom you filed a 1996

return, complete lines 7 – 12. If you are divorced or your spouse is deceased, you must complete

Part III and Part IV.

7. Your name :___________________________ 8. Your SSN: _______|______|__________

9. Spouse’s name:_______________________ 10. Spouse SSN: _______|______|_________

11. Your current mailing address: ______________________________________________

______________________________________________________

City

State

Zip Code

12. Amount of income tax surcharge from line 39 of the AR1000F or AR1000Nor line 14 of the AR1000S:

$__________

PART IV: Divorced or Deceased Joint Filers.

14. If you checked line 2, answer the following using your 1996 return and tax records:

a. Amount of net taxable income reported on line 37 of the AR1000F or AR1000Nor line 11 of the

AR1000S:

$__________

b. Amount of net taxable income attributable to you and not your spouse:

$________

c. Total tax reported on line 42 of the AR1000F or AR1000Nor line 15 of the AR1000S:

$________

15. If you checked line 4, answer the following using your 1996 return:

a. Amount of net taxable income reported on line 37 of the AR1000F or AR1000Nor line 11 of the

AR1000S:

You: $_________

Spouse: $__________

b. Total tax reported on line 42 of the AR1000F or AR1000Nor line 15 of the AR1000S: $________

School District Surcharge Refund Claim