Form 1-Nr/py - Mass. Nonresident/part-Year Resident Tax Return - 2012 Page 4
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6SOCIAL SECURITY NUMBER
2012 FORM 1-NR/PY
PAGE 4
37
Voluntary fund contributions:
0 0
0 0
a. Endangered Wildlife Conservation 3 37a
d. Massachusetts U.S. Olympic . . . . . . . 3 37d
0 0
0 0
b. Organ Transplant . . . . . . . . . . . . . 3 37b
e. Mass. Military Family Relief . . . . . . . . 3 37e
0 0
0 0
c. Massachusetts AIDS . . . . . . . . . . . 3 37c
f. Homeless Animal Prevention And Care 3 37f
0 0
Total. Add lines 37a through 37f . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
0 0
38
Use tax due on out-of-state purchases (from worksheet). If no use tax due enter “0” . . . . . . . . . . . 3 38
39
Health Care penalty for certain part-year residents (from worksheet; be sure to enclose Schedule HC):
0 0
0 0
0 0
+
=
a. You 3
b. Spouse 3
a
b
. . . . . . . . . . . . . . . . . . . . . . . . . . 39
0 0
40
INCOME TAX AFTER CREDITS, CONTRIBUTIONS, USE TAX and HC PENALTY. Add lines 36–39 . . . . 40
41
Massachusetts income tax withheld (enclose all Massachusetts Forms W-2, W-2G, 2-G,
0 0
PWH-WA, LOA and certain 1099s, if applicable) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 41
42
2011 overpayment applied to your 2012 estimated tax (from 2011 Form 1, line 45 or Form 1-NR/PY,
0 0
line 50; do not enter 2011 refund) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 42
0 0
43
2012 Massachusetts estimated tax payments (do not include amount in line 42) . . . . . . . . . . . . . 3 43
0 0
44
Payments made with extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 44
45
Earned Income Credit: a. Number of qualifying children 3
(Nonresidents, multiply this amount
0 0
0 0
by line 14g; part-year residents
× .15 =
Amount from U.S. return 3
. . . . . . . 3 45
multiply this amount by line 2)
0 0
46
Senior Circuit Breaker Credit (part-year residents only; enclose Schedule CB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 46
0 0
47
Other refundable credits from Schedule RF, line 4 (enclose Schedule RF) . . . . . . . . . . . . . . . . . . . . 3 47
0 0
48
TOTAL. Add lines 41 through 47 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
49
OVERPAYMENT. If line 40 is smaller than line 48, subtract line 40 from line 48. If line 40 is larger
0 0
than line 48, go to line 52. If line 40 and line 48 are equal, enter “0” in line 51 . . . . . . . . . . . . . . . . 3 49
0 0
50
Amount of overpayment you want APPLIED to your 2013 ESTIMATED TAX . . . . . . . . . . . . . . . . . . 3 50
51
THIS IS YOUR REFUND. Subtract line 50 from line 49.
0 0
Mail to: Massachusetts DOR, PO Box 7000, Boston, MA 02204 . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 51
Direct Deposit of Refund. See instructions.
Type of account (you must select one): 3
Checking
Savings
3
3
Routing number (first two digits must be 01–12 or 21–32)
Account number
52
TAX DUE. Subtract line 48 from line 40. Pay online at , or use
0 0
Form PV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 52
Pay in full. Write Social Security number(s) on lower left corner of check and be sure to sign check.
Make payable to Commonwealth of Massachusetts. Mail to: Massachusetts DOR, PO Box 7003, Boston, MA 02204.
Add to total in line 52, if applicable:
0 0
0 0
0 0
Interest 3
Penalty 3
M-2210 amount 3
Exception. Enclose Form M-2210
3
BE SURE TO SIGN RETURN ON PAGE 1 AND ENCLOSE SCHEDULE HC (IF APPLICABLE).
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