Form Ia-22 - Questionnaire Of Earnings Allocations printable pdf download

QUESTIONNAIRE OF EARNINGS ALLOCATIONS

A review of your return discloses that you lived and/or worked in more than one state during the tax year _____________.

Please complete this questionnaire for you and/or your spouse, in order that a proper allocation of income can be made on

your Kansas individual income tax return, and return in the enclosed envelope or mail to: Kansas Department of Revenue,

Correspondence, 915 SW Harrison St. Topeka, Kansas 66625-2007.

1. Did you live in Kansas during tax period? (

) Yes_____

No______

2. If married filing joint, did spouse live in Kansas during tax period? (

)

Yes_____

No______

If you answered “No” to question 1 and question 2, then stop here and mail form to the Kansas Department of Revenue

3. What dates were you a Kansas resident? From:___/____/______ to ___/____/______

4. What dates was your spouse a Kansas resident? From: ___/____/______ to ___/____/______

5. List employers while a Kansas resident:

1. Employer Name_____________________________

a. Employer location (city and state)_____________________________________

b. Dates worked for this employer: From ___/____/______ to ___/____/______

c. Total income earned from this employer: $______________

d. Income earned while living in Kansas: $ ______________

e. Name of person who worked for this employer (you or your spouse): ____________________

2. Employer Name_____________________________

a. Employer location (city and state)_____________________________________

b. Dates worked for this employer: From ___/____/______ to ___/____/______

c. Total income earned from this employer: $______________

d. Income earned while living in Kansas: $ ______________

e. Name of person who worked for this employer (you or your spouse): ____________________

3. Employer Name_____________________________

a. Employer location (city and state)_____________________________________

b. Dates worked for this employer: From ___/____/______ to ___/____/______

c. Total income earned from this employer: $______________

d. Income earned while living in Kansas: $ ______________

e. Name of person who worked for this employer (you or your spouse): ____________________

4. Employer Name_____________________________

a. Employer location (city and state)_____________________________________

b. Dates worked for this employer: From ___/____/______ to ___/____/______

c. Total income earned from this employer: $______________

d. Income earned while living in Kansas: $ ______________

e. Name of person who worked for this employer (you or your spouse): ____________________

If you have more employers please complete and submit additional IA-22 form(s).

IA-22

(Rev. 8/07)

Form Ia-22 - Questionnaire Of Earnings Allocations