Form M-8453 - Individual Income Tax Declaration For Electronic Filing

2013

Form M-8453

Massachusetts

Individual Income Tax Declaration

epartment of

for Electronic Filing

Revenue

Please print or type. Privacy Act Notice available upon request. For the year January 1– December 31, 2013.

Your first name and initial

Last name

Your Social Security number

If a joint return, spouse’s first name and initial

Last name

Spouse’s Social Security number

Present street address (and apartment number)

City/Town/Post Office

State

Zip

Filing status:

Single

Married filing jointly

Married filing separately

Head of household

Part 1. Tax Return Information for Electronic Filing

1 Total 5.25% income (from Form 1, line 10, or Form 1-NR/PY, line 12). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2 Income tax after credits (from Form 1, line 31, or Form 1-NR/PY, line 36). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 Massachusetts use tax (from Form 1, line 33, or Form 1-NR/PY, line 38) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

4 Massachusetts income tax withheld (from Form 1, line 36, or Form 1-NR/PY, line 41) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

5 Refund amount (from Form 1, line 46, or Form 1-NR/PY, line 51) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

6 Tax due (from Form 1, line 47, or Form 1-NR/PY, line 52) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Under pains and penalties of perjury, I declare that I have reviewed the information on my return with the information I have provided to my Electronic

Part 2.

eclaration and Signature of Taxpayer

Return Originator and that the amounts above agree with the amounts shown on my 2013 Massachusetts return. To the best of my knowledge and belief

this information is true, correct and complete. I consent that my return, including this declaration and accompanying schedules, forms and statements be

sent to the Massachusetts Department of Revenue by my Electronic Return Originator. I authorize DOR to inform my Electronic Return Originator and/or

the transmitter when my electronic return has been accepted. In the event that it is rejected, I authorize DOR to identify the reasons for rejection so that

the return can be corrected and re-transmitted. If I have filed a balance due return, I understand that if DOR does not receive full and timely payment of

my tax liability, I will remain liable for the tax liability and all applicable penalties and interest.

Your signature

Date

Spouse’s signature (if joint return, both must sign)

Date

I declare that I have reviewed the above taxpayer’s return and that the entries on this M-8453 are complete and correct to the best of my knowledge.

Part 3.

eclaration and Signature of Electronic Return Originator (ERO)

(Collectors are not responsible for reviewing the taxpayer’s return; however, they must ensure that the M-8453 accurately reflects the data on the return.)

I have obtained the taxpayer’s signature before submitting this return to the Massachusetts Department of Revenue. I have provided the taxpayer with

a copy of all forms and information filed with the Massachusetts Department of Revenue. If I am also the paid preparer, under pains and penalties of

perjury I declare that I have examined the above taxpayer’s return and accompanying schedules and statements and to the best of my knowledge and

belief, they are true, correct and complete. I declare that I have verified the taxpayer’s proof of account and it agrees with the name(s) shown on this form.

This declaration of paid preparer (other than taxpayer) is based on all information of which the preparer has any knowledge. Original Forms M-8453

should not be sent to DOR, but must instead be retained by the ERO on the ERO’s business premises for a period of three years from the date the return

to which the M-8453 relates was filed.

ERO’s signature and SSN or PTIN

Date

EIN

Check if

self-employed

Firm name (or yours, if self-employed) and address

City/Town

State

Zip

Check if also

paid preparer

Under pains and penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of

Part 4.

eclaration and Signature of Paid Preparer (if other than ERO)

my knowledge and belief it is true, correct and complete. This declaration of paid preparer (other than taxpayer) is based on all information of which the

preparer has any knowledge.

Paid preparer’s signature and SSN or PTIN

Date

EIN

Check if

self-employed

Firm name (or yours, if self-employed) and address

City/Town

State

Zip

printed on recycled paper