Form 1040-Es (Nr) - Estimated Tax Payment Voucher - 2016 Page 7

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Record of Estimated Tax Payments (Farmers, fishermen, and fiscal year taxpayers, see page 2 for payment due dates.)
Keep for Your Records
(c) Check or
(d) Amount paid
(e) 2015
(f) Total amount
Payment
(a) Amount
(b) Date
money order number or
(do not include
overpayment
paid and credited
due
due
paid
credit or debit card
date
(add (d) and (e))
any convenience fee)*
credit applied
confirmation number
1
Apr. 18, 2016
2
Jun. 15, 2016
3
Sep. 15, 2016
4
Jan. 17, 2017**
Total
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* You can deduct the convenience fee charged by the service provider in 2016 as a miscellaneous itemized deduction (subject to the 2%-of-AGI limit) on your 2016 income
tax return.
** You do not have to make this payment if you file your 2016 tax return by January 31, 2017, and pay the entire balance due with your return.
Tear off here
4
1040-ES (NR)
2016
Estimated Tax
Department of the Treasury
Payment Voucher
OMB No. 1545-0074
Internal Revenue Service
Calendar year—Due Jan. 17, 2017
File only if you are making a payment of estimated tax by check or money order. Return this
Amount of estimated tax you are
voucher with your check or money order payable to “United States Treasury.” Write your
paying by
identifying number and “2016 Form 1040-ES (NR)” on your check or money order. Do not send
Dollars
Cents
check or
cash. Enclose, but do not staple or attach, your payment with this voucher.
money order.
Your identifying number (SSN or ITIN) (employer identification number for an estate or trust)
Your first name and initial
Your last name
Address (number, street, and apt. no.)
City, state, and ZIP code.
Foreign country name
Foreign province/state/county
Foreign postal code
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
-7-

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