Form D-400 - Individual Income Tax Return - 2012 Page 4
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Last Name (First 10 Characters)
Tax Year
Your Social Security Number
2012
D-400 Web-Fill
9-12
Computation of North Carolina Taxable Income for Part-Year Residents and Nonresidents
(See Line Instructions beginning on Page 15. Note: Do not complete Lines 51 through 53 if you were a full-year resident.)
Fill in applicable circles
You
Spouse
Fill in circle(s) if you or your spouse moved into or out of North Carolina during the year and enter the dates of residency in the boxes.
You
Spouse
Date residency began
Date residency ended
Date residency began
Date residency ended
(MM-DD-YY)
(MM-DD-YY)
(MM-DD-YY)
(MM-DD-YY)
Fill in circle(s) if you or your spouse were nonresidents of North Carolina for the entire year.
Part-year residents and nonresidents must read the instructions on Page 15 and complete the worksheet on Page 16 to determine the amounts to enter
on Lines 51 and 52 below.
51. Enter the amount from Column B, Line 33 of the Part-Year
51.
Resident/Nonresident Worksheet on Page 16 of the Instructions.
52.
Enter the amount from Column A, Line 33 of the Part-Year
52.
Resident/Nonresident Worksheet on Page 16 of the Instructions.
53. Divide Line 51 by Line 52
(Enter the result as a decimal amount here and on Line 16; round
53.
to four decimal places.)
I certify that, to the best of my knowledge, this return is
If prepared by a person other than taxpayer, this certification is
accurate and complete.
based on all information of which the preparer has any knowledge.
Your Signature
Date
Paid Preparer’s Signature
Date
Spouse’s Signature (If filing joint return, both must sign.)
Date
Preparer’s FEIN, SSN, or PTIN
Home Telephone Number (Include area code.)
Preparer’s Telephone Number (Include area code.)
N.C. DEPT. OF REVENUE
If you ARE NOT due a
N.C. DEPT. OF REVENUE
If REFUND mail
return to:
P.O. BOX R
refund, mail return, any
P.O. BOX 25000
RALEIGH, NC 27634-0001
payment, and D-400V to:
RALEIGH, NC 27640-0640
Original Return Payment Options
Online – You can pay your tax online by bank draft, credit, or debit card using Visa or MasterCard. Go to
and click on Electronic Services for details.
Payment voucher – If you do not pay your tax online, go to and generate a personalized Form D-400V.
Enclose the voucher with your return and payment, and mail to the address listed above. If you do not pay online or by
payment voucher, mail a check or money order with your return for the full amount due. Please write “D-400”, and your
name, address, and social security number on the payment. If filing a joint return, write both social security numbers on
your payment in the order that they appear on the return. Note: The Department will not accept a check, money order,
or cashier’s check unless it is drawn on a U.S. (domestic) bank and the funds are payable in U.S. dollars. Please do
not staple, tape, paper clip, or otherwise attach your payment or voucher to your return or to each other.
Amended Returns
See Form D-400X for the mailing address and payment options for amended returns.
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