Form 1-Nr/py - Massachusetts Nonresident/part-Year Resident Tax Return - 2014

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CERTAIN PART-YEAR RESIDENTS
FOR PRIVACY ACT NOTICE,
SEE INSTRUCTIONS.
MUST ENCLOSE SCHEDULE HC
Form 1-NR/PY
Mass. Nonresident/Part-Year Resident Tax Return
2014
FIRST NAME
M.I.
LAST NAME
1. YOUR SOCIAL SECURITY NUMBER
SPOUSE’S FIRST NAME
M.I.
LAST NAME
2. SPOUSE’S SOCIAL SECURITY NUMBER
ADDRESS
CITY/TOWN/POST OFFICE/FOREIGN COUNTRY
STATE
ZIP + 4
ADDRESS OF LEGAL RESIDENCE OR DOMICILE (IF FILING AS NONRESIDENT)
CITY/TOWN/POST OFFICE/FOREIGN COUNTRY
STATE OR FOREIGN COUNTRY
Total
State Election Campaign Fund (this contribution will not change your tax or reduce your refund). . . . . . . . . . . . . . .
$1 You
$1 Spouse if filing jointly . . . . .
Fill in if veteran of U.S. armed forces who served in Operation Enduring Freedom, Iraqi Freedom or Noble Eagle 3
You 3
Spouse
3 $
If taxpayer(s) is deceased, fill in appropriate oval(s); see instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Primary
Spouse
Under age 18; see instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
You 3
Spouse
Select only one:
Nonresident
Filing as both a nonresident and
Fill in if name/address has changed since 2013
3
Part-year resident
part-year resident (see instructions)
Fill in if noncustodial parent
3
Nonresident composite return (see inst.)
Fill in if filing Schedule TDS (see instructions)
3
1
Single
FILING STATUS
3
(select one only)
Married filing joint return
(both must sign return)
Married filing separate return
(enter spouse’s Social Security number in the appropriate space above)
Head of household
You are a custodial parent who has released claim to exemption for child(ren)
(see instructions) 3
2
PART-YEAR RESIDENTS ONLY
Dates as Massachusetts resident: From 3
To 3
=
Total days as Massachusetts resident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
÷ 365
3 2
Whole-dollar method only
3
TOTAL INCOME from U.S. 1040, line 22; 1040A, line 15; 1040EZ, line 4; 1040NR, line 23;
0 0
or 1040NR-EZ, line 7. If married filing separately, see instructions. . . . . . . . . . . . . . . . . . . . . . . . 3 3
If showing a loss, mark an X in box at left
1
4
EXEMPTIONS
a. Personal exemptions. If single or married filing separately, enter $4,400. If head of household, enter $6,800.
0 0
If married filing jointly, enter $8,800 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4a
0 0
=
× $1,000
b. Number of dependents. (Do not include yourself or your spouse.)
Enter number 3
4b
You must enclose Schedule DI.
0 0
=
c. Age 65 or over before 2015:
You
Spouse
Enter number 3
× $ 700
4c
0 0
=
d. Blindness:
You
Spouse
Enter number 3
× $2,200
4d
e. 1. Medical/
0 0
0 0
0 0
+
=
Dental 3
2. Adoption 3
1
2
4e
From U.S. Schedule A, line 4
See instructions
0 0
f. TOTAL EXEMPTIONS. Add lines 4a through 4e. Enter here and on line 22a. . . . . . . . . . . . . . . . . . . . . . . 3 4f
INCOME
Nonresidents report in lines 5 through 11 Massachusetts source income only. Use line 13 if appropriate. Part-year residents report in
lines 5 through 11 income earned and/or received while a resident. Do not use lines 13 or 14. If filing both as a nonresident and part-year
resident, be sure to complete and enclose Schedule R/NR, Resident/Nonresident Worksheet, before proceeding any further.
0 0
5
Wages, salaries, tips and other employee compensation (from all Forms W-2) . . . . . . . . . . . . . . . . . 3 5
0 0
6
Taxable pensions and annuities (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 6
SIGN HERE. Under penalties of perjury, I declare that to the best of my knowledge and belief this return and enclosures are true, correct and complete.
Your signature
Date
Print paid preparer’s name
Preparer’s SSN
or PTIN
3
/
/
Spouse’s signature (if filing jointly)
Date
Paid preparer’s phone
Paid preparer’s
(
)
EIN
3
/
/
May DOR discuss this return with the preparer?
Yes
Paid preparer’s signature
Date
Fill in if self-employed
3
3
I do not want my preparer to file my return electronically
3
/
/

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