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MISSOURI INDIVIDUAL INCOME TAX RETURN

2011

FORM MO-1040A

SINGLE/MARRIED (INCOME FROM ONE SPOUSE)—SHORT FORM

SOFTWARE

LAST NAME

FIRST NAME

MIDDLE INITIAL

DECEASED

SOCIAL SECURITY NUMBER

VENDOR CODE

2011

(Assigned by DOR)

–

SPOUSE’S LAST NAME

FIRST NAME

MIDDLE INITIAL

DECEASED

SPOUSE’S SOCIAL SECURITY NUMBER

002

2011

–

IN CARE OF NAME (ATTORNEY, EXECUTOR, PERSONAL REPRESENTATIVE, ETC.)

COUNTY OF RESIDENCE

PRESENT ADDRESS (INCLUDE APARTMENT NO. OR RURAL ROUTE)

CITY, TOWN, OR POST OFFICE, STATE, AND ZIP CODE

AGE 65 OR OLDER

BLIND

100% DISABLED

NON-OBLIGATED SPOUSE

PLEASE CHECK THE APPROPRIATE

BOXES THAT APPLY TO YOURSELF

YOURSELF

OR YOUR SPOUSE.

SPOUSE

1. Federal adjusted gross income from your 2011 Federal Forms 1040—Line 37;

1040A—Line 21; or 1040EZ—Line 4 ....................................................................................................................

2 –

2. Any state income tax refund included in your 2011 federal adjusted gross income .............................................

3 =

3. Total Missouri adjusted gross income — Subtract Line 2 from Line 1. .................................................................

4. M ark your filing status box below and enter the appropriate exemption amount on Line 4.

A. Single — $2,100 (See Box B before checking.)

D. Married filing separate — $2,100

E. Married filing separate (spouse

B. C laimed as a dependent on another person’s federal

NOT filing) — $4,200

tax return — $0.00

F. Head of household — $3,500

C. M arried filing joint federal & combined Missouri — $4,200

Check which spouse had income:

G. Qualifying widow(er) with

dependent child — $3,500

Spouse

Yourself

5. Tax from federal return (Do not

Enter this amount on Line 5 or $5,000, whichever is less.

enter federal income tax withheld.) —

If married filing combined, enter this amount on Line 5

or $10,000, whichever is less. ...........................................

6. Missouri standard deduction or itemized deductions. Single or Married Filing Separate— $5,800; Head of

Household — $8,500; Married Filing a Combined Return or Qualifying Widow(er) — $11,600. If you are age 65 or

older, blind, or claimed as a dependent, see your federal return or page 7.

6 +

If you are itemizing, see back of form. .....................................................................................................................

7. Number of dependents you claimed on your Federal Form 1040 or 1040A, Line 6c

7 +

(Do not include yourself or your spouse.) ...........................................................

x $1,200 = ..............

8 +

8. Long-term care insurance deduction ......................................................................................................................

9 =

9. Total Deductions — Add Lines 4 through 8. ...........................................................................................................

10. Missouri Taxable Income — Subtract Line 9 from Line 3. ......................................................................................

11. Tax — Use the tax table on the back of this form to figure the tax. ........................................................................

1 2. Missouri tax withheld from your Forms W-2 and Forms 1099. Attach copies of Forms W-2 and Forms 1099. ....

1 3. Any Missouri estimated tax payments made for 2011 .............................................................................................

14. Total Payments — Add Lines 12 and 13. ...............................................................................................................

15. If Line 14 (Total Payments) is more than Line 11 (Total Tax), enter the difference (amount of overpayment)

here. (If Line 14 is less than Line 11, skip to Line 19.) ..........................................................................................

1 6. Amount from Line 15 that you want applied to your 2012 estimated tax. ............................................................

17. Enter the amount

Additional

eneral

Workers

LEAD

of your donation in

Fund Code

Missouri

evenue

(See Instr.)

the trust fund boxes

Veterans

Elderly Home

Childhood

Military

General

Children’s

National Guard

Workers’

After School

Trust Fund

Delivered Meals

Family Relief

Organ Donor

Trust Fund

Memorial Fund

Lead Testing

Revenue

Retreat

______|______

to the right. See the

Trust Fund

Fund

Program Fund

instructions for

fund codes. ........ 17.

18. Subtract Lines 16 and 17 from Line 15 and enter here. This is your refund. Sign below and mail to:

Department of Revenue, P.O. Box 500, Jefferson City, MO 65106-0500. ......................................... REFUND

19. If Line 14 is less than Line 11, enter the difference here. You have an amount due. Sign below and mail to:

Department of Revenue, P.O. Box 329, Jefferson City, MO 65107-0329. ........................AMOUNT YOU OWE

If you pay by check, you authorize the Department of Revenue to process the check electronically. Any check returned unpaid may be presented again electronically.

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

preparer (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. I also declare under penalties of perjury that I employ no illegal or unauthorized aliens as defined under federal law and that I am not eligible for any tax exemption, credit or abatement if I employ such aliens.

I authorize the Director of Revenue or delegate to discuss my return and attachments with

E-MAIL ADDRESS

PREPARER’S PHONE

the preparer or any member of the preparer’s firm.

YES

(

)

SIGNATURE

DATE

PREPARER’S SIGNATURE

FEIN, SSN, OR PTIN

SPOUSE’S SIGNATURE