Form Inc 250 Draft - Individual Income Tax Return

Tennessee Department Of Revenue

INC

Individual Income Tax Return

250

Filing Period

Due Date

Beginning:

Account Number

Ending:

NOTE TO VENDORS: This is the area for

the 2-D barcode. If you are not producing a

2-D return, please leave this area blank.

NOTE TO VENDORS:

This is the address area

Developer’s Code

}

If this is an AMENDED RETURN,

YOUR SSN:

please check the box at right

SPOUSE'S SSN:

Because a portion of the tax goes back to the city or county of residence, please provide the

FEIN:

county and city (if within an incorporated municipality) of the taxpayer’s legal residence on

Please mail payments to:

the lines below.

Tennessee Department of Revenue

County _______________________________________________

Andrew Jackson State Office Building

500 Deaderick Street

City _________________________________________________

Nashville, TN 37242-0300

AFFIDAVIT FOR EXEMPTION

For tax years beginning January 1, 2000, any person 65 years of age or older having a total annual income derived from any and all sources of $16,200 or

less, or any persons who file a joint return and either spouse is 65 years of age or older having a total annual joint income derived from any and all sources

of not more than $27,000 may qualify for a total exemption from income tax. IF YOU QUALIFY FOR THE EXEMPTION, DO NOT COMPLETE THE

SCHEDULES BELOW. CHECK THE BOX AT RIGHT AND SIGN RETURN ON THE BACK.

CHECK ALL BOXES WHICH APPLY:

1. Single

6. Blind

9. Partnership

(yourself)

Limited

2. Married Filing Jointly

4. Quadriplegic

7. Blind

10. Liability

(yourself)

(your spouse)

Company

3. Married Filing Separately

5. Quadriplegic

8. Trust

11. Estate

(enter spouse's SSN # above)

(your spouse)

ROUND TO THE NEAREST DOLLAR

TAX COMPUTATION

1. GROSS TAXABLE INCOME (From Schedule A) .................................................................. (1)

{

$1,250 if single or married filing separately

2. SUBTRACT EXEMPTION

............................. (2)

$2,500 if married filing jointly

3. AMOUNT SUBJECT TO TAX (Line 1 less Line 2) .......................

(3)

4. INCOME TAX (6% of Line 3) ........................................................

(4)

5. ENTER: Estimated tax payment for taxable year ................................................................... (5)

If filed late, compute penalty at 5% of the tax (Line 4 minus Line 5) for each 1 to 30 DAY

{

6. PENALTY

PERIOD for which TAX IS DELINQUENT (Total penalty NOT TO EXCEED 25%.) Minimum

................ (6)

penalty is $15 regardless of the amount of tax due or whether there is any tax due

{

If filed late, compute interest at 8.25% per annum on the tax (Line 4 minus

7. INTEREST

........................................ (7)

Line 5) from the due date of payment to the date paid

8. TOTAL AMOUNT DUE (Add Lines 4, 6, and 7; subtract Line 5) ........................................... (8)

9. REFUND (If Line 5 exceeds total of Lines 4, 6, and 7, enter overpayment here) .................... (9)

FOR OFFICE

USE ONLY

RV-R0003501

Form Inc 250 Draft - Individual Income Tax Return - 2001

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