Form Mo-1040c - Residents/nonresidents With Other State Income And Active Duty Military - Short Form - 2004

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2004 FORM MO-1040C
MISSOURI DEPARTMENT OF REVENUE
RESIDENTS/NONRESIDENTS WITH OTHER STATE INCOME
AND ACTIVE DUTY MILITARY
VENDOR CODE
— SHORT FORM
(Assigned by DOR)
SOCIAL SECURITY NUMBER
SPOUSE’S SOCIAL SECURITY NUMBER
NAME (LAST)
(FIRST)
M.I. JR, SR
SPOUSE’S (LAST)
(FIRST)
M.I. JR, SR
IN CARE OF NAME (ATTORNEY, EXECUTOR, PERSONAL REPRESENTATIVE, ETC.)
PRESENT ADDRESS (INCLUDE APARTMENT NO. OR RURAL ROUTE)
COUNTY OF RESIDENCE
SCHOOL DISTRICT NO.
PLEASE CHECK THE APPROPRIATE BOXES THAT APPLY TO YOURSELF OR YOUR SPOUSE.
CITY, TOWN, OR POST OFFICE
STATE
ZIP CODE
AGE 65 OR OLDER
BLIND
100% DISABLED
NON-OBLIGATED SPOUSE
YOURSELF
YOURSELF
YOURSELF
YOURSELF
SPOUSE
SPOUSE
SPOUSE
SPOUSE
Yourself
Spouse
1. Federal adjusted gross income from your 2004 federal return
1
00
00
(See worksheet.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
00
00
2. Any state income tax refund included in your 2004 federal income . . . . . . . . . . . . . .
3
00
00
3. Subtract Line 2 from Line 1. This is your Missouri Adjusted Gross Income. . . . . . .
4
00
4. Total Missouri Adjusted Gross Income — Add both numbers on Line 3. . . . . . . . . . . . . . . . . .
5
%
%
5. Income percentages: Divide Line 3 by Line 4 for both you and your spouse. (Both must equal 100%.)
6.
Mark your filing status box below. Enter the appropriate exemption amount (from box checked) on Line 6.
A. Single — $2,100 (See Box B before checking.)
D. Married filing separate — $2,100
B. Claimed as a dependent on another person’s
E. Married filing separate (spouse
federal tax return — $0.00
NOT filing) — $4,200
C. Married filing joint federal & combined Missouri
F. Head of household — $3,500
6
00
— $4,200
G. Qualifying widow(er) w/dep. child—$3,500
7. Tax from federal return. (Do not enter amount
Single—max. of $5,000;
00
7
00
from Form W-2(s)—NOT federal tax withheld).
Married—max. of $10,000
8. Missouri standard deduction or itemized deductions. Single — $4,850; Head of Household— $7,150;
Married Filing Separate — $4,850; Married Filing a Combined Return or Qualifying Widow(er) — $9,700;
8
00
If claimed as a dependent, age 65 or older, or blind, see federal return. If itemizing, see back of form. . .
9. Number of dependents you claimed on your Federal Form 1040 OR 1040A,
9
00
Line 6c. (Do not include yourself or your spouse.) . . . . . . . . . . . . . . . . . . .
x $1,200 =
10
00
10. Long-term care insurance deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
00
11. Total Deductions — Add Lines 6 through 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
00
12. Taxable Income — Subtract Line 11 from Line 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
00
00
13. Multiply Line 12 by the percentages on Line 5 for you and your spouse. . . . . . . . . .
14
00
00
14. Use table on back to figure tax on amounts from Line 13 for you and your spouse ..
OR
15
00
00
15. Resident credit (Attach Form MO-CR and other state’s returns.)
. . .
16
%
%
16. Missouri income percentage (Attach Form MO-NRI and federal return.)
. . . .
OR
17. Balance (Resident — Subtract Line 15 from Line 14)
17
00
00
(Missouri Income Percentage — Multiply Line 14 by Line 16.) . . . . . . . . . . . . . .
18
00
18. Total Taxes. Add your tax and your spouse’s tax from Line 17. . . . . . . . . . . . . . . . . . . . . . . . . .
19
00
19. Missouri tax withheld for you and your spouse from your Form W-2(s) and Form 1099(s) . . . . . . . .
20
00
20. Any Missouri estimated tax payments you made for 2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
21
00
21. Total Payments — Add Lines 19 and 20. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
22. If Line 21 (Total Payments) is more than Line 18 (Total Taxes), enter the difference (amount of
22
00
overpayment) here. (If Line 21 is less than Line 18, skip to Line 26.) . . . . . . . . . . . . . . . . . . . .
23
00
23. Amount from Line 22 that you want applied to next year’s taxes. . . . . . . . . . . . . . . . . . . . . . . . .
Trust Fund Code
Children’s
Veterans
Elderly Home
Missouri National
Workers’
Trust Fund Code
24. Enter the amount of your donation
Workers
Delivered Meals
Guard
Memorial
(See Instr.) ____|____
(See Instr.) ____|____
24
00
00
00
00
00
00
00
in the trust fund boxes to the right. .
25. Subtract Lines 23 and 24 from Line 22 and enter here. This is your refund. Sign below and
REFUND
25
00
mail to: Department of Revenue, P.O. Box 500, Jefferson City, MO 65106-0500. . . . . . . . . . . . . . .
26. If Line 21 is less than Line 18, enter the difference here. You have an amount due. Sign below and
AMOUNT YOU OWE
26
00
mail to: Department of Revenue, P.O. Box 329, Jefferson City, MO 65107-0329. . . . . . . .
The Department of Revenue may electronically resubmit checks returned for insufficient or uncollected funds.
DOR
S E P
F
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief it is true, correct, and complete. Declaration of pre-
ONLY
parer (other than taxpayer) is based on all information of which he/she has any knowledge. As provided in Chapter 143, RSMo, a penalty of up to $500 shall be imposed on any individual who files a frivolous return.
PAID PREPARER’S PHONE
I authorize the Director of Revenue or delegate to discuss my return and attachments with the preparer or any member of the preparer’s firm.
YES
NO
X
SIGNATURE
DATE
PAID PREPARER’S SIGNATURE
FEIN, SSN, OR PTIN
SPOUSE’S SIGNATURE
DAYTIME TELEPHONE
PAID PREPARER’S ADDRESS AND ZIP CODE
DATE
For Privacy Notice, see the instructions.
MO 860-2903 (11-2004)

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