Form 1-NR-PY Nonresident or Part-Year Resident Income Tax Return

$ 700 = 4c $1 000 = 4b $2 200 = 4d 12 = 27 TAX ON LONG TERM CAPITAL GAINS (from Schedule D line 22) Not less than 0 Enclose Schedule D If filing Sched D IS Installment Sales fill in oval and enclose Schedule D IS 3 15 = multiply this amount by line 2) 3 45 46 Senior Circuit Breaker Credit (part year residents only; enclose Schedule CB) 3 46 47 Other refundable credits from Schedule RF line 4 (enclose Schedule RF) 3 47 48 TOTAL Add lines 41 through 47 48 26 12% INCOME from Schedule B line 39 Not less than 0 (enclose Schedule B) 365 = 3 2 a b = 7 Fill in if self employed FIRST NAME FIRST NAME FIRST NAME FIRST NAME FIRST NAME Massachusetts income Multiply line 13e by line 13f Enter here and in appropriate lines on Non Massachusetts source income Not less than 0 See instructions 3 14e SOCIAL SECURITY NUMBER SOCIAL SECURITY NUMBER SOCIAL SECURITY NUMBER SOCIAL SECURITY NUMBER SOCIAL SECURITY NUMBER Total 5 25% income (from line 12) Not less than 0 14a Total capital gain income if any (total of Schedule B Part 1 line 7; Schedule B Part 2 line 13; Total income being apportioned (you cannot apportion Mass wages as shown on Form W 2) 13f $1 Spouse if filing jointly Total Fill in if veteran of U S armed forces who served in Operation Enduring Freedom Iraqi Freedom or Noble Eagle 3 $1 You $2 000 (Medicare premiums deducted from your Soc Sec or retirement payments are not deductible ) 3 15b (from Form 1 NR/PY line 4b) by $1 000 and add $14 400 to that amount If line 10 is less than or (from line 4f) a (Nonresidents multiply this amount by line 14g; part year residents (select one only) / / ( ) EIN 3 / / or PTIN 3 1 + 2 = 4e 1 5 25% income from this return (from Form 1 NR/PY line 12) 1 10 a Unemployment compensation See instructions 3 10a 10 Massachusetts Adjusted Gross Income (AGI) Subtract line 9 from line 8 Not less than 0 10 11 If married and filing a joint return multiply the number of dependents (from Form 1 NR/PY line 4b) 11 Other income (alimony taxable IRA /Keogh distribution winnings fees) from Schedule X line 5 (enclose Schedule X; not less than 0 ) 3 11 12 If you do not qualify for No Tax Status and you are married and filing a joint return multiply the 12 TOTAL 5 25% INCOME Add lines 5 through 11 (Be sure to subtract any loss(es) in lines 8 or 9) 12 13 No Tax Status threshold Enter $8 000 if single If married filing a joint return or head of household 13 NONRESIDENT APPORTIONMENT WORKSHEET You cannot apportion Massachusetts wages as shown on Form W 2 Do not use this work sheet if you know the exact amount of your Massachusetts source income Use only when income from employment/business is earned both inside and outside Massachusetts and the exact Massachusetts amount is not known Basis: 14 Income for Limited Income Credit Subtract line 13 from line 10 14 14 NONRESIDENT DEDUCTION & EXEMPTION RATIO Nonresident taxpayers must complete this item to determine the ratio for apportioning the deductions in lines 16 and 17; certain Schedule Y deductions (see instructions); the exemptions in line 22a; and the EIC in line 45 15 a Amount you paid to Social Security Medicare Railroad U S or Mass retirement Not more than $2 000 (Medicare premiums deducted from your Soc Sec or retirement payments are not deductible ) 3 15a 15 Tax before adjustments (from Form 1 NR/PY line 32 less any Credit Recapture Amount entered 16 Tax for Limited Income Credit Multiply line 14 by 10% ( 10) 16 17 Limited Income Credit Subtract line 16 from line 15 and enter the result here and in line 33 of 2 Adjustments to income (enter the total of Schedule Y lines 1 through 10) 2 2 Adoption 3 2012 FORM 1 NR/PY PAGE 2 2012 FORM 1 NR/PY PAGE 3 3 28 If excess exemptions were used in calculating lines 24 27 or 28 fill in oval (see instructions) 3 3 Adjusted 5 25% income from this return Subtract line 2 from line 1 Not less than 0 3 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): 4 Interest exemption used (from Form 1 NR/PY enter the smaller of line 7a or line 7b) 4 41 Massachusetts income tax withheld (enclose all Massachusetts Forms W 2 W 2G 2 G 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 line 50; do not enter 2011 refund) 3 42 43 2012 Massachusetts estimated tax payments (do not include amount in line 42) 3 43 44 Payments made with extension 3 44 45 Earned Income Credit: a Number of qualifying children 3 49 OVERPAYMENT If line 40 is smaller than line 48 subtract line 40 from line 48 If line 40 is larger than line 48 go to line 52 If line 40 and line 48 are equal enter 0 in line 51 3 49 5 25% INCOME AFTER DEDUCTIONS Subtract line 20 from line 12 Not less than 0 21 Exemption amount 5 Adjusted gross interest dividends and certain capital gains (from Schedule B line 35) If there is no 5 If showing a loss mark an X in box at left 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 Mail to: Massachusetts DOR PO Box 7000 Boston MA 02204 3 51 52 TAX DUE Subtract line 48 from line 40 Pay online at www mass gov / dor/payonline or use Form PV 3 52 6 Long term capital gain income From Schedule D line 19 Not less than 0 6 7 a 3 7 Additional income/loss while a nonresident/part year resident See instructions 3 7 8 Business/profession or farm income/loss (enclose Massachusetts Schedule C or U S 8 Total income Combine lines 3 through 7 Not less than 0 8 9 Additional adjustments to income while a nonresident/part year resident See instructions 3 9 9 If you are reporting rental royalty REMIC partnership S corporation trust income/loss a + b = 39 40 INCOME TAX AFTER CREDITS CONTRIBUTIONS USE TAX and HC PENALTY Add lines 36 39 40 a Endangered Wildlife Conservation 3 37a a You 3 Add to total in line 52 if applicable: Additional tax on installment sale (see instructions) 3 30 ADDRESS CITY/ TOWN/POST OFFICE /FOREIGN COUNTRY ADDRESS OF LEGAL RESIDENCE OR DOMICILE (IF FILING AS NONRESIDENT) CITY/ TOWN/POST OFFICE /FOREIGN COUNTRY STATE OR FOREIGN COUNTRY Amount from U S return 3 and add $25 200 to that amount Enter the result here If line 10 is less than or equal to line 12 Attach with a single staple state copy of Forms W 2 W 2G and 1099 (showing Massachusetts withholding) b Amount your spouse paid to Social Security Medicare Railroad U S or Mass retirement Not more than b Massachusetts state lottery winnings 3 10b b Organ Transplant 3 37b b Spouse 3 BE SURE TO SIGN RETURN ON PAGE 1 AND ENCLOSE SCHEDULE HC (IF APPLICABLE) by $1 000 and add $16 400 to that amount If head of household multiply the number of dependents c Age 65 or over before 2013: c Massachusetts AIDS 3 37c CERTAIN PART YEAR RESIDENTS FOR PRIVACY ACT NOTICE SEE INSTRUCTIONS Checking Savings Child under age 13 or disabled dependent /spouse care expenses (from worksheet) 3 16 Credit recapture amount (enclose Schedule H 2; see instructions) BC CREDITS Limited Income Credit Complete and enclose Schedule NTS L NR/PY 3 33 Credits from Schedule Z line 9 (enclose Schedule Z) 3 34 Credits from Schedule Z line 12 (part year residents only; enclose Schedule Z) 3 35 INCOME TAX AFTER CREDITS Subtract total of lines 33 through 35 from line 32 Not less than 0 36 d Blindness: You d Massachusetts U S Olympic 3 37d DATE OF BIRTH DATE OF BIRTH DATE OF BIRTH DATE OF BIRTH DATE OF BIRTH Dates as Massachusetts resident: From 3 Deduction and exemption ratio Divide line 14d by line 14f 14g DEDUCTIONS Amounts entered in line(s) 15a and/or 15b must be related to Massachusetts income reported on this return Direct Deposit of Refund See instructions Type of account (you must select one): 3 e 1 Medical/ Dental 3 e Mass Military Family Relief 3 37e enter the amount from line 11 13 entry in Schedule B line 35 or if not filing Schedule B enter the amount from Form 1 NR/PY line 24 equal to line 11 you qualify for No Tax Status See the instructions for Form 1 NR/PY Exception Enclose Form M 2210 Exemption: if married filing jointly subtract $200 from line 7a; otherwise subtract $100 and enter result (not less than 0 ) EXEMPTIONS f Homeless Animal Prevention And Care 3 37f f TOTAL EXEMPTIONS Add lines 4a through 4e Enter here and on line 22a 3 4f Filing as both a nonresident and 3 FILING STATUS 3 Fill in if filing Schedule TDS (see instructions) Fill in if name/address has changed since 2011 Part year resident Fill in if noncustodial parent Nonresident composite return (see inst ) 3 FIRST NAME M I LAST NAME Form 1 NR / PY Mass Nonresident /Part Year Resident Tax Return 2012 Form 1 NR/PY If line 15 is smaller than line 16 you are not eligible for this credit 17 From U S Schedule A line 4 See instructions Head of household (see instructions) 3 HR 3 29 I do not want my preparer to file my return electronically 3 If head of household multiply the number of dependents (from Form 1 NR/PY line 4b) by $1 750 If you are single and the total in line 10 is $8 000 or less you qualify for No Tax Status Fill in the oval in line 31 enter 0 in line 32 and continue completing Form 1 NR/PY However if there is an amount entered in line 29 Credit Recapture Amount and/or line 30 Additional Tax on Installment Sales enter that amount in line 32 and complete lines 34 and 35 If you are single but do not qualify for No Tax Status and your total in line 10 is $14 000 or less go to line 13 to see if you qualify for the Limited Income Credit If you qualify for No Tax Status fill in oval and enter 0 on line 32 Complete Schedule NTS L NR/PY 3 TOTAL INCOME TAX Add lines 26 through 30 32 in line 29 and/or Additional Tax on Installment Sales entered in line 30) 15 INCOME Nonresidents report in lines 5 through 11 Massachusetts source income only Use line 13 if appropriate Part year residents report in lines 5 through 11 income earned and/or received while a resident Do not use lines 13 or 14 If filing both as a nonresident and part year resident be sure to complete and enclose Schedule R/NR Resident/Nonresident Worksheet before proceeding any further Interest 3 Penalty 3 M 2210 amount 3 3 Interest income (smaller of line 7a or line 7b) 14b IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT? IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT? IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT? IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT? IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT? LAST NAME LAST NAME LAST NAME LAST NAME LAST NAME line 31 11 Make payable to Commonwealth of Massachusetts Mail to: Massachusetts DOR PO Box 7003 Boston MA 02204 Married filing joint return (both must sign return) Married filing separate return (enter spouse s Social Security number in the appropriate space above) Massachusetts bank interest Exemption amount Massachusetts ratio Divide line 13b by line 13c 3 13e May DOR discuss this return with the preparer? 3 Yes 3 Paid preparer s signature Date miles MUST ENCLOSE SCHEDULE HC Nonresidents during 2012 did you have a family home or any other dwelling outside Massachusetts to which you generally or customarily returned or intend to return in the future? Yes No If Yes you do not qualify for this deduction Nonresidents multiply line 22a by line 14g Nonworking days (holidays weekends etc ) 13d Not less than 0 5 Not more than two: a 3 $3 600 = Nonresidents multiply result by line 14g; part year residents multiply result by line 2 3 17 00 Number of dependent member(s) of household under age 12 or dependents age 65 or over (not you or your spouse) as of December 31 2012 Number of dependents (Do not include yourself or your spouse ) Enter number 3 number of dependents (from Form 1 NR/PY line 4b) by $1 750 and add $28 700 to that amount or disabled dependent(s) (only if single head of household or married filing joint return and not claiming line 16) or your spouse If you are claiming more than 10 dependents see instructions Other deductions from Schedule Y line 17 (enclose Schedule Y) 3 19 other: pages 1 and 2 13g part year resident (see instructions) 3 Part year residents multiply line 22a by line 2 3 22 5 25% INCOME AFTER EXEMPTIONS Subtract line 22 from line 21 Not less than 0 If line 21 is less than line 22 see instructions 23 INTEREST AND DIVIDEND INCOME from Schedule B line 38 Not less than 0 (enclose Schedule B) 3 24 PART YEAR RESIDENTS ONLY Pay in full Write Social Security number(s) on lower left corner of check and be sure to sign check Personal exemptions If single or married filing separately enter $4 400 If head of household enter $6 800 If married filing jointly enter $8 800 4a RELATIONSHIP TO TAXPAYER RELATIONSHIP TO TAXPAYER RELATIONSHIP TO TAXPAYER RELATIONSHIP TO TAXPAYER RELATIONSHIP TO TAXPAYER RELATIONSHIP TO TAXPAYER IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT? DATE OF BIRTH Rental deduction Total rental deduction cannot exceed $3 000 ($1 500 if married filing separately) See instructions Routing number (first two digits must be 01 12 or 21 32) Account number sales Schedule D line 13 Not less than 0 ) 14c Schedule F) 3 8 Schedule NTS L NR/PY No Tax Status and Limited Income Credit 2012 see instructions 3 9 SIGN HERE Under penalties of perjury I declare that to the best of my knowledge and belief this return and enclosures are true correct and complete Single SOCIAL SECURITY NUMBER SOCIAL SECURITY NUMBER Spouse 3 $ If taxpayer(s) is deceased fill in appropriate oval(s); see instructions 3 Primary Spouse Enter number 3 SPOUSE S FIRST NAME M I LAST NAME 2 SPOUSE S SOCIAL SECURITY NUMBER Spouse s signature (if filing jointly) Date Paid preparer s phone Paid preparer s Spouse Select only one: Nonresident Spouse Under age 18; see instructions 3 You 3 State Election Campaign Fund (this contribution will not change your tax or reduce your refund) TAX ON 5 25% INCOME (from tax table) If line 25 is more than $24 000 multiply by 0525 Note: If choosing the optional 5 85% tax rate multiply line 25 and the amount in Schedule D line 21 by 0585 See instructions; fill in oval 3 Taxable pensions and annuities (see instructions) 3 6 Total Add lines 37a through 37f 37 Total days as Massachusetts resident TOTAL DEDUCTIONS Add lines 15 through 19 3 20 Total income Add line 14d and line 14e See instructions 14f Total income this return Add lines 14a b and c 14d Total Massachusetts rent paid in 2012: a 3 00 2 = 3 18 00 TOTAL TAXABLE 5 25% INCOME Add lines 23 and 24 25 Total working days Add line 13a and line 13b 13c Wages salaries tips and other employee compensation (from all Forms W 2) 3 5 Whole dollar method only TOTAL INCOME from U S 1040 line 22; 1040A line 15; 1040EZ line 4; 1040NR line 23; or 1040NR EZ line 7 If married filing separately see instructions 3 3 1 If showing a loss mark an X in box at left working days Working days (or other basis) inside Massachusetts 13b Working days (or other basis) outside Massachusetts 13a You 3 You are a custodial parent who has released claim to exemption for child(ren) you may qualify for the Limited Income Credit Go to line 13 12 You must complete this schedule if you are claiming a dependent exemption(s) on Form 1 line 2b or Form 1 NR/PY line 4b or taking a deduction/ credit(s) on Form 1 lines 12 13 or 40 or Form 1 NR/PY lines 16 17 or 45 Complete information below for each dependent Do not include yourself You must enclose Schedule DI Your signature Date Print paid preparer s name Preparer s SSN