Form K-40 - Kansas Individual Income Tax And/or Food Sales Tax Refund - 2012
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1
22012
K-40
114512
KANSAS INDIVIDUAL INCOME TAX
(Rev. 7/12)
and/or FOOD SALES TAX REFUND
DO NOT STAPLE
Your First Name
Initial Last Name
Enter the first four letters of your last name.
Use ALL CAPITAL letters.
Spouse's First Name
Initial Last Name
Your Social
Security number
Mailing Address (Number and Street, including Rural Route)
School District No.
Enter the first four letters of your spouse's
last name. Use ALL CAPITAL letters.
City, Town, or Post Office
Zip Code
County Abbreviation
State
Spouse's Social
Security number
If your name or address has changed since last year, mark an "X" in this box
Daytime
telephone
If taxpayer (or spouse if filing joint) died during this tax year, mark an "X" in this box
number
Amended
If this is an AMENDED 2012 Kansas return mark one of the following boxes:
Return
Amended affects Kansas only
Amended Federal tax return
Adjustment by the IRS
(Mark ONE)
Filing Status
Married filing joint
Head of household (Do not
Single
Married filing separate
(Mark ONE)
(Even if only one had income)
mark if filing a joint return)
Residency
Status
Part-year resident from ___ / ___ / ___
to ___ / ___ / ___
Nonresident
Resident
(Complete Sch. S, Part B)
(Complete Sch. S, Part B)
(Mark ONE)
Exemptions
Enter the number of exemptions you claimed on your 2012 federal return. If no federal return is required, enter total
and
exemptions for you, your spouse (if applicable), and each person you claim as a dependent.
Dependents
If filing status above is Head of household, add one exemption.
Total Kansas exemptions.
In the following spaces, provide the requested information for all persons you claimed as dependents. Do NOT include you or your spouse. If additional
space is needed, enclose a separate schedule.
Name (please print)
Date of Birth (mm/dd/yy)
Relationship
SSN (Social Security Number)
________________________________________
________________
________________________________________
________________
________________________________________
________________
________________________________________
________________
________________________________________
________________
________________________________________
________________
________________________________________
________________
Food Sales
If you were a Kansas resident for all 2012, complete this section to determine if you qualify for a Food Sales Tax refund.
Tax
{
A. Had a dependent child who lived with you all year and was under the age of 18 all of 2012?. . . . .
YES
NO
Qualification
Mark
ONE
B. Were you (or spouse) 55 years of age or older during 2012 (born prior to January 1, 1958)? . . . . .
YES
NO
box
C. Were you (or spouse) totally and permanently disabled or blind all of 2012, regardless of age? . . .
YES
NO
D. If you answered YES to A, B, or C, complete the worksheet on page 11 and enter the
QUALIFYING INCOME from line 14. If line 14 is zero, you must enter "0" here. If line
00
14 is a negative amount, shade the box. Example:
E. If amount on line D is less than $36,701 , see instructions in the tax booklet to figure your
00
refund. Enter the amount here. This is your FOOD SALES TAX REFUND. . . . . . . . . . .
If you are filing for a Food Sales Tax refund only, you do not need to complete lines 1 through 40. Just SIGN this return on
the back and mail it to the address shown below. Refunds are not issued for unsigned returns.
Mail to: Kansas Income Tax, Kansas Dept. of Revenue
915 SW Harrison St., Topeka, KS 66699-1000
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