Form 1040-Es (Nr) - Estimated Tax Payment Voucher - 2012 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) 2011
(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
04/17/2012
2
06/15/2012
3
09/17/2012
4
01/15/2013**
Total
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*You can deduct the convenience fee charged by the service provider in 2012 as a miscellaneous itemized deduction (subject to the 2%-of-AGI limit) on your 2012 income
tax return.
** You do not have to make this payment if you file your 2012 tax return by January 31, 2013, and pay the entire balance due with your return.
Privacy Act and Paperwork Reduction
retained as long as their contents may
Please keep this notice with your
Act Notice. We ask for this information to
records. It may help you if we ask you for
become material in the administration of
other information. If you have any
carry out the tax laws of the United States.
any Internal Revenue law. Generally, tax
returns and return information are
questions about the rules for filing and
We need it to figure and collect the right
amount of tax. Our legal right to ask for this
confidential, as stated in Code section
giving information, please call or visit any
information is Internal Revenue Code
6103.
Internal Revenue Service office.
section 6654, which requires that you pay
We may disclose the information to the
The average time and expenses required
your taxes in a specified manner to avoid
Department of Justice for civil or criminal
to complete and file this form will vary
being penalized. Additionally, section 6001,
litigation and to other federal agencies, as
depending on individual circumstances.
6011, and 6012(a) and their regulations
provided by law. We may disclose it to
For the estimated averages, see the
require you to file a return or statement for
cities, states, the District of Columbia, and
instructions for your income tax return.
any tax for which you are liable; section
U.S. commonwealths or possessions to
If you have suggestions for making this
6109 requires you to provide your
carry out their tax laws. We may also
package simpler, we would be happy to
identifying number. Failure to provide this
disclose this information to other countries
hear from you. See the instructions for your
information, or providing false or fraudulent
under a tax treaty, to federal and state
income tax return.
information, may subject you to penalties.
agencies to enforce federal nontax criminal
You are not required to provide the
laws, or to federal law enforcement and
information requested on a form that is
intelligence agencies to combat terrorism.
subject to the Paperwork Reduction Act
If you do not file a return, do not give the
unless the form displays a valid OMB
information asked for, or give fraudulent
control number. Books or records relating
information, you may be charged penalties
to a form or its instructions must be
and be subject to criminal prosecution.
Tear off here
4
1040-ES (NR)
2012
Estimated Tax
Department of the Treasury
Payment Voucher
OMB No. 1545-0074
Internal Revenue Service
Calendar year—Due Jan. 15, 2013
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 the “United States Treasury.” Write your
paying by
identifying number and “2012 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. If a foreign address, enter city, province or state, and country. Include postal code.
For Privacy Act and Paperwork Reduction Act Notice, see above.
-7-

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