8734
2015
State Use Only
IDAHO GROCERY CREDIT REFUND
24
F
O
You or Your Spouse Must Be Age 65 or Older
R
EFO00086
M
05-29-15
Your first name and initial
Last name
Your Social Security number
Deceased
in 2015
If a joint return, spouse's first name and initial
Last name
Spouse's Social Security number
Deceased
in 2015
Current mailing address
City, State, and Zip Code
A. INCOME
1. Enter your gross income. Include wages, salaries, tips, interest, dividends,
self-employment income before expenses, farm income before expenses,
rental income before expenses, and pensions. Enter 0 if your only income is from
Social Security benefits and/or Veterans Administration disability benefits ......
1
2. Enter the amount for your filing status from the filing status chart.
2
See instructions, Part A, Income .....................................................................................
.
3. Compare lines 1 and 2 . ..................................................................................................
If line 1 is equal to or larger than line 2, you can't use this form. You
must file an income tax return, Form 40, to receive your grocery credit.
.
If line 1 is less than line 2, continue.
B. REFUND CLAIMED
YOURSELF
SPOUSE
1. Enter the date of birth ..............................................................
Month
Day
Year
Month
Day
Year
2. Check the boxes that apply.
.
.
Under age 65 .......................................................... $100 per person
.
.
Age 65 or older ....................................................... $120 per person
.
3. If you're donating your grocery credit to the Cooperative Welfare Fund,
check here and the $0 total refund claimed box.This donation is irrevocable.
$0
$120
$220
$240
.
4. Total refund claimed (Check one box) .............................................................
.
Check if final deposit destination is outside of the U.S.
.
5. DIRECT DEPOSIT. See instructions.
.
.
Checking
.
Type of
Account No.
Routing No.
Savings
Account:
C. SIGNATURE(S) REQUIRED
If anyone other than the surviving spouse signs on
If you or your spouse are unable to sign, your
behalf of a deceased person, IRS Form 1310 must
representative must write "unable to sign" in
be completed and included.
the signature space(s) and enter his or her
name, address, and relationship.
Your signature
Phone number
Date
.
X
Spouse's signature (if a joint return, BOTH MUST SIGN)
.
X
{"T!¦}
MAIL TO:
Idaho State Tax Commission
PO Box 56
Boise, ID 83756-0056