C 847 GRAND CHAMPION DRIVEf01.justanswer.com/aLkeN8Z3/anurag+gupta_17_6809+(FRO... · 2017. 4....

Form 1040 Department of the Treasury—Internal Revenue Service (99)U.S. Individual Income Tax Return 2016 OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.

For the year Jan. 1–Dec. 31, 2016, or other tax year beginning , 2016, ending , 20 See separate instructions.Your first name and initial Last name Your social security number

If a joint return, spouse’s first name and initial Last name Spouse’s social security number

Make sure the SSN(s) above and on line 6c are correct.

Home address (number and street). If you have a P.O. box, see instructions. Apt. no.

City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions).

Foreign country name Foreign province/state/county Foreign postal code

Presidential Election Campaign

Check here if you, or your spouse if filing jointly, want $3 to go to this fund. Checking a box below will not change your tax or refund. You Spouse

Filing Status

Check only one box.

1 Single

2 Married filing jointly (even if only one had income)

3 Married filing separately. Enter spouse’s SSN above and full name here.

4 Head of household (with qualifying person). (See instructions.) If the qualifying person is a child but not your dependent, enter this

child’s name here.

5 Qualifying widow(er) with dependent child

Exemptions 6a Yourself. If someone can claim you as a dependent, do not check box 6a . . . . .b Spouse . . . . . . . . . . . . . . . . . . . . . . . . }c Dependents:

(1) First name Last name

(2) Dependent’s social security number

(3) Dependent’s relationship to you

(4) if child under age 17 qualifying for child tax credit

(see instructions)

If more than four dependents, see instructions and check here

d Total number of exemptions claimed . . . . . . . . . . . . . . . . .

Boxes checked on 6a and 6bNo. of children on 6c who: • lived with you • did not live with you due to divorce or separation (see instructions)

Dependents on 6c not entered above

Add numbers on lines above

Income

Attach Form(s) W-2 here. Also attach Forms W-2G and 1099-R if tax was withheld.

If you did not get a W-2, see instructions.

7 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . 7

8a Taxable interest. Attach Schedule B if required . . . . . . . . . . . . 8a

b Tax-exempt interest. Do not include on line 8a . . . 8b

9 a Ordinary dividends. Attach Schedule B if required . . . . . . . . . . . 9a

b Qualified dividends . . . . . . . . . . . 9b

10 Taxable refunds, credits, or offsets of state and local income taxes . . . . . . 10

11 Alimony received . . . . . . . . . . . . . . . . . . . . . 11

12 Business income or (loss). Attach Schedule C or C-EZ . . . . . . . . . . 12

13 Capital gain or (loss). Attach Schedule D if required. If not required, check here 13

14 Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . 14

15 a IRA distributions . 15a b Taxable amount . . . 15b

16 a Pensions and annuities 16a b Taxable amount . . . 16b

17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E 17

18 Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . . 18

19 Unemployment compensation . . . . . . . . . . . . . . . . . 19

20 a Social security benefits 20a b Taxable amount . . . 20b

21 Other income. List type and amount 21 22 Combine the amounts in the far right column for lines 7 through 21. This is your total income 22

Adjusted Gross Income

23 Educator expenses . . . . . . . . . . . 23

24 Certain business expenses of reservists, performing artists, and fee-basis government officials. Attach Form 2106 or 2106-EZ 24

25 Health savings account deduction. Attach Form 8889 . 25

26 Moving expenses. Attach Form 3903 . . . . . . 26

27 Deductible part of self-employment tax. Attach Schedule SE . 27

28 Self-employed SEP, SIMPLE, and qualified plans . . 28

29 Self-employed health insurance deduction . . . . 29

30 Penalty on early withdrawal of savings . . . . . . 30

31 a Alimony paid b Recipient’s SSN 31a

32 IRA deduction . . . . . . . . . . . . . 32

33 Student loan interest deduction . . . . . . . . 33

34 Tuition and fees. Attach Form 8917 . . . . . . . 34

35 Domestic production activities deduction. Attach Form 8903 35

36 Add lines 23 through 35 . . . . . . . . . . . . . . . . . . . 36 37 Subtract line 36 from line 22. This is your adjusted gross income . . . . . 37

For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2016)

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BAA REV 01/25/17 PRO

Form 1040 (2016) Page 2

Tax and Credits

38 Amount from line 37 (adjusted gross income) . . . . . . . . . . . . . . 38

39a Check if:

{ You were born before January 2, 1952, Blind.Spouse was born before January 2, 1952, Blind.

} Total boxes checked 39a

b If your spouse itemizes on a separate return or you were a dual-status alien, check here 39b Standard Deduction for— • People who check any box on line 39a or 39b or who can be claimed as a dependent, see instructions. • All others: Single or Married filing separately, $6,300 Married filing jointly or Qualifying widow(er), $12,600 Head of household, $9,300

40 Itemized deductions (from Schedule A) or your standard deduction (see left margin) . . 40

41 Subtract line 40 from line 38 . . . . . . . . . . . . . . . . . . . 41

42 Exemptions. If line 38 is $155,650 or less, multiply $4,050 by the number on line 6d. Otherwise, see instructions 42

43 Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter -0- . . 43

44 Tax (see instructions). Check if any from: a Form(s) 8814 b Form 4972 c 44

45 Alternative minimum tax (see instructions). Attach Form 6251 . . . . . . . . . 45

46 Excess advance premium tax credit repayment. Attach Form 8962 . . . . . . . . 46

47 Add lines 44, 45, and 46 . . . . . . . . . . . . . . . . . . . 47

48 Foreign tax credit. Attach Form 1116 if required . . . . 48

49 Credit for child and dependent care expenses. Attach Form 2441 49

50 Education credits from Form 8863, line 19 . . . . . 50

51 Retirement savings contributions credit. Attach Form 8880 51

52 Child tax credit. Attach Schedule 8812, if required . . . 52

53 Residential energy credits. Attach Form 5695 . . . . 53

54 Other credits from Form: a 3800 b 8801 c 54

55 Add lines 48 through 54. These are your total credits . . . . . . . . . . . . 55

56 Subtract line 55 from line 47. If line 55 is more than line 47, enter -0- . . . . . . 56

Other Taxes

57 Self-employment tax. Attach Schedule SE . . . . . . . . . . . . . . . 57

58 Unreported social security and Medicare tax from Form: a 4137 b 8919 . . 58

59 Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required . . 59

60 a Household employment taxes from Schedule H . . . . . . . . . . . . . . 60a

b First-time homebuyer credit repayment. Attach Form 5405 if required . . . . . . . . 60b

61 Health care: individual responsibility (see instructions) Full-year coverage . . . . . 61

62 Taxes from: a Form 8959 b Form 8960 c Instructions; enter code(s) 62

63 Add lines 56 through 62. This is your total tax . . . . . . . . . . . . . 63

Payments 64 Federal income tax withheld from Forms W-2 and 1099 . . 6465 2016 estimated tax payments and amount applied from 2015 return 65

If you have a qualifying child, attach Schedule EIC.

66a Earned income credit (EIC) . . . . . . . . . . 66a

b Nontaxable combat pay election 66b

67 Additional child tax credit. Attach Schedule 8812 . . . . . 67

68 American opportunity credit from Form 8863, line 8 . . . 68

69 Net premium tax credit. Attach Form 8962 . . . . . . 69

70 Amount paid with request for extension to file . . . . . 70

71 Excess social security and tier 1 RRTA tax withheld . . . . 7172 Credit for federal tax on fuels. Attach Form 4136 . . . . 72

73 Credits from Form: a 2439 b Reserved c 8885 d 73

74 Add lines 64, 65, 66a, and 67 through 73. These are your total payments . . . . . 74

Refund

Direct deposit? See instructions.

75 If line 74 is more than line 63, subtract line 63 from line 74. This is the amount you overpaid 75

76a Amount of line 75 you want refunded to you. If Form 8888 is attached, check here . 76a

b Routing number c Type: Checking Savings

d Account number

77 Amount of line 75 you want applied to your 2017 estimated tax 77Amount You Owe

78 Amount you owe. Subtract line 74 from line 63. For details on how to pay, see instructions 7879 Estimated tax penalty (see instructions) . . . . . . . 79

Third Party Designee

Do you want to allow another person to discuss this return with the IRS (see instructions)? Yes. Complete below. NoDesignee’s name

Phone no.

Personal identification number (PIN)

Sign Here Joint return? See instructions. Keep a copy for your records.

Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and accurately list all amounts and sources of income I received during the tax year. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Your signature Date Your occupation Daytime phone number

Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent you an Identity Protection PIN, enter it here (see inst.)

Paid Preparer Use Only

Print/Type preparer’s name Preparer’s signature Date Check if self-employed

PTIN

Firm’s name

Firm’s address

Firm’s EIN

Phone no.

www.irs.gov/form1040 Form 1040 (2016)

PROGRAM ANALYST

PROGRAM ANALYST

196,573.

12,600.183,973.20,250.163,723.

29,519.

32,828.

32,828.

32,828.

32,828.

29,519.

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No

Self-Prepared

X X X X X X X X X

REV 01/25/17 PRO

PERSONAL DECLARATION OF ESTIMATED INCOME TAX

1. Return by

2. Make checks payable to COMPTROLLER OF MARYLAND - EST

3. DO NOT STAPLE PAYMENT TO FORM.4. Using BLACK PEN print AMOUNT OF

THIS PAYMENT in el belo .

502DEP2017

COM/RAD 039

SPOUSE’S SOCIAL SECURITY NUMBER (Required if applicable)YOUR SOCIAL SECURITY NUMBER (Required)

$

Return Address:

COMPTROLLER OF MARYLAND REVENUE ADMINISTRATION DIVISIONP.O. BOX 2903ANNAPOLIS, MD 21404-2903

A GC G847 GRAND CHAMPION DRIVE

ROCKVILLE, MD 20850

150 07 5600 G 2017 123 04 0560

1103

04/18/2017

17502P013

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REV 02/17/17 PRO


1. Return by




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COM/RAD 039


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Return Address:


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06/15/2017

150 07 5600 G 2017 123 04 0560


ROCKVILLE, MD 20850

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00

REV 02/17/17 PRO


1. Return by




502DEP2017

COM/RAD 039


$

Return Address:


1103

09/15/2017

150 07 5600 G 2017 123 04 0560


ROCKVILLE, MD 20850

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REV 02/17/17 PRO


1. Return by




502DEP2017

COM/RAD 039


$

Return Address:


1103

01/16/2018

150 07 5600 G 2017 123 04 0560


ROCKVILLE, MD 20850

17502P013

00

REV 02/17/17 PRO

DO NOT

MAIL

COM/RAD-059

MARYLAND FORM

EL101e-File DECLARATIONFOR ELECTRONIC FILING

2016

Part I Tax Return Information (whole dollars only)

1. Amount of overpayment to be applied to 2017 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.

2. Amount of overpayment to be refunded to you . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.

3. Total amount due (Pay in full by April 18, 2017. See instructions.) . . . . . . . . . . . . . . . . . . . . . . . . . . 3.

Keep this form for your records. Do not send this form to the State of Maryland unless specifically requested to do so. See Instructions on Page 2.

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First Name Initial Last Name SSN/Taxpayer Identification Number

Spouse's First Name Initial Spouse's Last Name SSN/Taxpayer Identification Number

Part II Taxpayer Declaration and Signature Authorization

Under penalties of perjury, I declare that I have compared the information contained on my electronic return with the information that I provided to my electronic return originator or entered on-line and that the name(s) and amounts described above agree with the amounts shown on the corresponding lines of my 2016 Maryland electronic income tax return. To the best of my knowledge and belief, my return is true, correct and complete. I consent that my return, including accompanying schedules and statements, be sent to the Maryland Revenue Administration Division by my electronic return originator or by my electronic return software provider.

Your PIN: check one box only

I authorize __________________________________________ to enter or generate my PIN

only if you are entering your own PIN and

Your signature _____________________________________________________________________________ Date _________________________

Spouse's PIN: check one box only

I authorize __________________________________________ to enter or generate my PIN

only if you are entering your own PIN and

Spouse's signature _________________________________________________________________________ Date _________________________

Practitioner PIN Method Returns Only

ERO’s EFIN/PIN.

ERO's signature ___________________________________________________________________________ Date _________________________

Do not enter all zeros.



REFUND

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X GURU ACCOUNTING NY LLC 1 5 5 5 7

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REV 01/25/17 PRO

2016 $

Dates of Maryland Residence (MM DD YYYY) FROM TO Other state of residence: If you began or ended legal residence in Maryland in 2016 place a P in the box. . . . . . . . . . . . . . . . . MILITARY: If you or your spouse has non-Maryland military income, place an M in the box. . . . . . . Enter Military Income amount here:

1. Single (If you can be claimed on another person’s tax return, use Filing Status 6.)2. Married filing joint return or spouse had no income3. Married filing separately, Spouse SSN 4. Head of household5. Qualifying widow(er) with dependent child 6. Dependent taxpayer (Enter 0 in Exemption Box (A) - See Instruction 7.)

PART-YEAR RESIDENTSee Instruction 26.

FILING STATUS

CHECK ONE BOX See Instruction 1 if you are required to file.

Your Social Security Number Spouse's Social Security Number

Your First Name Initial

Your Last Name

Spouse's First Name Initial

Spouse's Last Name

Current Mailing Address Line 1 (Street No. and Street Name or PO Box)

Current Mailing Address Line 2 (Apt No., Suite No., Floor No.) City or Town State ZIP Code

OR FISCAL YEAR BEGINNING 2016, ENDING

4 Digit Political Subdivision Code (See Instruction 6) Maryland Political Subdivision (See Instruction 6)

Physical Street Address Line 1 (Street No. and Street Name) (No PO Box)

Physical Street Address Line 2 (Apt No., Suite No., Floor No.) (No PO Box)

City State ZIP Code Maryland County

REQUIRED: Physical address as of December 31, 2016 or last day of the taxable year for fiscal year taxpayers. See Instruction 6. Part-year residents see Instruction 26.

EXEMPTIONSSee Instruction 10. Check appropriate box(es). NOTE: If you are claiming dependents, you must attach the Dependents' Information Form 502B to this form to receive the applicable exemption amount.

A. Yourself Spouse . . . . . . Enter number checked See Instruction 10 A. $

B. 65 or over 65 or over

Blind Blind Enter number checked X $1,000. . . . . . . B. $

C. Enter number from line 3 of Dependent Form 502B . . . . . . . . . See Instruction 10 C. $

D. Enter Total Exemptions (Add A, B and C.) . . . . . . . . . . . Total Amount D. $

MD

COM/RAD-009

MARYLAND FORM

502RESIDENT INCOMETAX RETURN

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165020013

REV 12/30/16 PRO

2016

NAME SSN

18. Net income (Subtract line 17 from line 16.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18. 19. Exemption amount from Exemptions area (See Instruction 10.) . . . . . . . . . . . . . . . . . . . . . . 19. 20. Taxable net income (Subtract line 19 from line 18.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.

MARYLANDTAX COMPUTATION

LOCAL TAX COMPUTATION

21. Maryland tax (from Tax Table or Computation Worksheet Schedules I or II) . . . . . . . . . . . . 21. 22. Earned income credit (½ of federal earned income credit. See Instruction 18.) . . . . . . . . . 22. 23. Poverty level credit (See Instruction 18.). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23. 24. Other income tax credits for individuals from Part K, line 11 of Form 502CR (Attach Form 502CR.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24. 25. Business tax credits 26. Total credits (Add lines 22 through 25.). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26. 27. Maryland tax after credits (Subtract line 26 from line 21.) If less than 0, enter 0. . . . . . . . . . 27.

. . . . . . . .You must file this form electronically to claim business tax credits on Form 500CR.

28. Local tax (See Instruction 19 for tax rates and worksheet.) Multiply line 20 by your local tax rate .0 or use the Local Tax Worksheet . . . . . . . . . . . . . . . . . . . . . 28. 29. Local earned income credit (from Local Earned Income Credit Worksheet in Instruction 19.) . . 29. 30. Local poverty level credit (from Local Poverty Level Credit Worksheet in Instruction 19.) . . . . 30. 31. Local tax credit from Part L, line 1 of Form 502CR (Attach Form 502CR.) . . . . . . . . . . . . . . 31. 32. Total credits (Add lines 29 through 31.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32. 33. Local tax after credits (Subtract line 32 from line 28.) If less than 0, enter 0 . . . . . . . . . . . . 33. 34. Total Maryland and local tax (Add lines 27 and 33.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34. 35. Contribution to Chesapeake Bay and Endangered Species Fund (See Instruction 20.) . . . . . 35. 36. Contribution to Developmental Disabilities Services and Support Fund (See Instruction 20.). 36. 37. Contribution to Maryland Cancer Fund (See Instruction 20.) . . . . . . . . . . . . . . . . . . . . . . 37. 38. Contribution to Fair Campaign Financing Fund (See Instruction 20.) . . . . . . . . . . . . . . . . . 38.

All taxpayers must select one method and check the appropriate box. STANDARD DEDUCTION METHOD (Enter amount on line 17.) ITEMIZED DEDUCTION METHOD (Complete lines 17a and 17b.) 17a. Total federal itemized deductions (from line 29, federal Schedule A) . 17a. 17b. State and local income taxes (See Instruction 14.) . . . . . . . . . . . . . 17b. Subtract line 17b from line 17a and enter amount on line 17.

17. Deduction amount (Part-year residents see Instruction 26 (l and m).) . . . . . . . . . . . . . . . 17.

DEDUCTION METHODSee Instruction 16.

8. Taxable refunds, credits or offsets of state and local income taxes included in line 1 . . . . . 8. 9. Child and dependent care expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. 10. Pension exclusion from worksheet in Instruction 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10. 11. Taxable Social Security and RR benefits (Tier I, II and supplemental) included in line 1 . . . 11. 12. Income received during period of nonresidence (See Instruction 26.) . . . . . . . . . . . . . . . . 12. 13. Subtractions from attached Form 502SU . . . . . . . . . . . . . . . . . . 13. 14. Two-income subtraction from worksheet in Instruction 13 . . . . . . . . . . . . . . . . . . . . . . . . 14. 15. Total subtractions from Maryland income (Add lines 8 through 14.) . . . . . . . . . . . . . . . . . 15. 16. Maryland adjusted gross income (Subtract line 15 from line 7.) . . . . . . . . . . . . . . . . . . . . . . 16.

SUBTRACTIONSFROM INCOMESee Instruction 13.

2. Tax-exempt interest on state and local obligations (bonds) other than Maryland . . . . . . . . 2. 3. State retirement pickup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. 4. Lump sum distributions (from worksheet in Instruction 12.) . . . . . . . . . . . . . . . . . . . . . . 4. 5. Other additions (Enter code letter(s) from Instruction 12.) . . . . 5. 6. Total additions to Maryland income (Add lines 2 through 5.) . . . . . . . . . . . . . . . . . . . . . . 6. 7. Total federal adjusted gross income and Maryland additions (Add lines 1 and 6.) . . . . . . . . . . . 7.

ADDITIONSTO INCOMESee Instruction 12.

1. Adjusted gross income from your federal return . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. 1a. Wages, salaries and/or tips. . . . . . . . . . . . . . . . . . . . . . 1a. 1b. Earned income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1b. 1c. Capital Gain or (loss) . . . . . . . . . . . . . . . . . . . . . . . . . . 1c. 1d. Taxable Pension, IRA, Annuities . . . . . . . . . . . . . . . . . . 1d. (Attach Form 502R.)

1e. Place a "Y" here in this box if the amount of your investment income is more than $3,400 . . . .

INCOMESee Instruction 11.

COM/RAD-009

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502RESIDENT INCOMETAX RETURN Page 2

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45. Balance due (If line 39 is more than line 44, subtract line 44 from line 39. See Instruction 22.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.

46. Overpayment (If line 39 is less than line 44, subtract line 39 from line 44.). . . . . . . . . . . . 46. 47. Amount of overpayment TO BE APPLIED TO 2017 ESTIMATED TAX 47. 48. Amount of overpayment TO BE REFUNDED TO YOU (Subtract line 47 from line 46.) See line 51 . . . . . . . . . . . . . . . . . . . . . . . . . . . REFUND 48. 49. Interest charges from Form 502UP or for late filing (See I nstruction 22.) Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49.

50. TOTAL AMOUNT DUE (Add lines 45 and 49.) IF $1 OR MORE, PAY IN FULL WITH THIS RETURN. INCLUDE FORM IND PV. . . . . . . . 50.

REFUND

AMOUNT DUE

NAME SSN

39. Total Maryland income tax, local income tax and contributions (Add lines 34 through 38.) . 39. 40. Total Maryland and local tax withheld (Enter total from your W-2 and 1099 forms if MD tax is withheld and attach.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40.

41. 2016 estimated tax payments, amount applied from 2015 return, payment made with an extension request, and Form MW506NRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41. 42. Refundable earned income credit (from worksheet in Instruction 21) . . . . . . . . . . . . . . . . 42. 43. Refundable income tax credits from Part M, line 6 of Form 502CR (Attach Form 502CR. See Instruction 21.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43. 44. Total payments and credits (Add lines 40 through 43.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44.

Your signature Date Signature of preparer other than taxpayer

Spouse’s signature Date Street address of preparer

City, State, ZIP

Telephone number of preparer Preparer’s PTIN (required by law)

COM/RAD-009

MARYLAND FORM

502RESIDENT INCOMETAX RETURN

Check here if you authorize your preparer to discuss this return with us. Check here if you authorize your paid preparer

not to file electronically. Check here if you agree to receive your 1099G Income Tax Refund statement electronically. (See

Instruction 24.)

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. If prepared by a person other than taxpayer, the declaration is based on all information of which the preparer has any knowledge.

DIRECT DEPOSIT OF REFUND (See Instruction 22.) Be sure the account information is correct. For Splitting Direct Deposit, see Form 588. If this refund will go to an account outside of the United States, then to comply with banking rules, place a "Y" in this box

and see Instruction 22. For the direct deposit option, complete the following information clearly and legibly.

51a. Type of account: Checking Savings

51b. Routing Number (9-digits) 51c. Account Number

Daytime telephone no. Home telephone no. CODE NUMBERS (3 digits per line)

For returns filed with payments, attach check or money order to Form IND PV. Make checks payable to Comptroller of Maryland. Do not attach Form IND PV or check/money order to Form 502. Place Form IND PV with attached check/money order on top of Form 502 and mail to:

Comptroller of Maryland Payment ProcessingPO Box 8888 Annapolis, MD 21401-8888

For returns filed without payments, mail your completed return to:

Comptroller of Maryland Revenue Administration Division 110 Carroll Street Annapolis, MD 21411-0001

6916

10297

6916

03381

3381

150075600A & C G

SELF-PREPARED

REV 12/30/16 PRO

165020213

MARYLANDFORM

502B2016Dependents' Information

(Attach to Form 502, 505 or 515.)

COM/RAD-026

First Name Initial Last Name

Social Security Number Relationship Regular 65 or over DEPENDENT 1


Social Security Number Relationship Regular 65 or over









DEPENDENT 2

DEPENDENT 3

DEPENDENT 4

DEPENDENT 5

DEPENDENT 6

Summary

1. Enter the total number checked below for Regular dependents (4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2. Enter the total number checked below for dependents 65 or over (5) . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Total dependent exemptions (Add lines 1 and 2 and enter the total here and on line (C) of the

Exemptions area of Form 502, 505 or 515.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.

Dependents (If a dependent listed below is age 65 or over, please check both 4 and 5.)

1.

2. 3. 4. 5.

1.

2. 3. 4. 5.

1.

2. 3. 4. 5.

1.

2. 3. 4. 5.

1.

2. 3. 4. 5.

1.

2. 3. 4. 5.



Your Last Name


Spouse's Last Name

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150075600

C

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123040560

30

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090113131 PARENT X

U G

090115464 PARENT X

A G

090564564 SON X

16502B013

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MARYLANDFORM

502CRINCOME TAX CREDITS FOR INDIVIDUALSAttach to your tax return.

COM/RAD-012

2016Pr

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1. Enter your taxable net income from line 20, Form 502 (or line 10, Form 504). . . . . . . . . . . . . . . . . . . . . . . . 1.2. Taxable net income in other state. Write on this line only the net income which is taxable in both the other state

and Maryland. If you are taxed in the other state on income which is not taxable in Maryland, do not include that

amount here. NOTE: When the tax in the other state is a percentage of a tax based on your total income regardless of source, you must apply the same percentage to your taxable income in the other state to

determine the income taxable in both states. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Revised taxable net income (Subtract line 2 from line 1.) If less than zero, enter zero. . . . . . . . . . . . . . . . . . . 3.4. Enter the Maryland tax from line 21, Form 502 (or line 11, Form 504). This is the Maryland tax based on your

total income for the year. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5. Tax on amount on line 3. Compute the Maryland tax that would be due on the revised taxable net income by

using the Maryland Tax Table or Computation Worksheet contained in the instructions for Forms 502 or 504.

Do not include the local income tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.6. Tentative State tax credit (Subtract line 5 from line 4.) If less than zero, enter zero. . . . . . . . . . . . . . . . . . . . 6.7. Enter the Local tax from line 28, Form 502 (or line 18, Form 504). This is the Local tax based on your total

income for the year. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.8. Local tax on amount on line 3. Compute the Local tax that would be due on the revised taxable net income by

multiplying line 3 by your Local tax rate .0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.9. Tentative Local tax credit (Subtract line 8 from line 7.) If less than zero, enter zero. . . . . . . . . . . . . . . . . . . . 9.10. Tentative Total tax credit (Add line 6 and line 9.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.11. Total state and local tax shown on tax return(s) filed with the state of (Enter 2-letter state code, code must be

entered for credit to be allowed) Enter the amount of your 2016 income tax liability (after deducting

any credits for personal exemptions) to the other state and locality in the other state (where applicable). Do not

enter state or locality tax withheld from your W-2 forms. It is important that a copy of the tax return that was filed with the other state and/or locality be attached to your Maryland return . . . . . . . . . . . . . 11.

12. Credit for income tax paid to other state and/or locality. Your credit for taxes paid to another state and/or locality is the smaller of the tax actually paid (line 11) or the reduction in Maryland tax resulting from the exclusion of

income in the other state and/or locality (line 10). Write the lesser of line 11 or line 10. . . . . . . . . . . . . . . . 12.State and Local Credits Allowed13. State Credit for Income Tax Paid to other state (Lesser of line 6 or line 12). Enter on line 1, Part K . . . . . . 13.14. Local Credit for Income Tax Paid to other state (Subtract line 13 from line 12.) Enter on line 1, Part L . . . . 14.

Read Instructions for Form 502CR. Note: You must complete and submit pages 1 through 3 of this form to receive credit for the items listed.

PART A - TAX CREDITS FOR INCOME TAXES PAID TO OTHER STATES AND LOCALITIES

If you were a part-year resident, do not claim a credit for tax paid on nonresident income you included on line 12 of the Form 502.

If you are claiming a credit for taxes paid to multiple states and/or localities, see instructions.



Your Last Name


Spouse's Last Name

A

G

150075600

C

G

123040560

187373

85711101662

8972

47764196

5996

320 325327436939

VA

4671

4671

4196475

16502C013

REV 02/07/17 PRO

MARYLANDFORM


COM/RAD-012

2016Page 2

NAME SSN

PART B - CREDIT FOR CHILD AND DEPENDENT CARE EXPENSES 1. Enter your federal adjusted gross income from line 1 of Form 502 or line 17, column 1 of

Form 505 or Form 515 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.

2. Enter your federal Child and Dependent Care Credit from federal Form 2441 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.

3. Enter the decimal amount from the chart in the instructions that applies to the amount on line 1 . . . . . . . . . . . . . 3.

4. Multiply line 2 by line 3. Enter here and on Part K, line 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.

PART C - QUALITY TEACHER INCENTIVE CREDIT1. Enter the Maryland public school system or a State or local correctional

facility or qualified juvenile facility in which you are employed and teach . . . . . . . 1. 1.

2. Enter amount of tuition paid to: . . . . . . . . . . . . . . . . 2. 2.

3. Enter amount of tuition reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. 3.

4. Subtract line 3 from line 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. 4.

5. Maximum credit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. 5.

6. Enter the lesser of line 4 or line 5 here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. 6.

7. Total (Add amounts from line 6, for Taxpayers A and B) Enter here and

on Part K, line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.

PART D - CREDIT FOR AQUACULTURE OYSTER FLOATS1. Enter the amount paid to purchase an aquaculture oyster float(s)

Enter here and on Part K, line 4. This credit is limited. See Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.

PART E - LONG-TERM CARE INSURANCE CREDIT: (THIS IS A ONE-TIME CREDIT.)Answer the questions and see instructions below before completing Columns A through E for each person

for whom you paid long-term care insurance premiums.

Question 1 - Did the insured individual have long-term care insurance prior to July 1, 2000? . . . . . . . . . . . . . . . . . . . . . . . . Yes NoQuestion 2 - Is the credit being claimed for the insured individual in this year by any other taxpayer? . . . . . . . . . . . . . . . . . . Yes NoQuestion 3 - Has credit been claimed by anyone for the insured individual in any other tax year? . . . . . . . . . . . . . . . . . . . . Yes NoQuestion 4 - Is the insured individual for whom the credit is being claimed a nonresident of Maryland? . . . . . . . . . . . . . . . . . Yes NoIf you answered YES to any of the above questions, that insured person does NOT qualify for the credit.Complete Columns A through D only for insured individuals who qualify for credit. Enter in Column E the lesser of the amount of premium paid for

each insured person or: • $390 for those insured who are 40 or less, as of 12/31/16

• $500 for those insured who are over age 40, as of 12/31/16.

Add the amounts in Column E and enter the total on line 5 (total) and on Part K, line 5.

Column AName of Qualifying Insured

IndividualAge

Column BSocial Security No.

of Insured

Column CRelationship to

Taxpayer

Column DAmount of Premium Paid

Column ECredit Amount

1. 1.2. 2.3. 3.4. 4.5. TOTAL 5.

Enter the Name of Qualified Employer Taxpayer A Taxpayer B

PART F - CREDIT FOR PRESERVATION AND CONSERVATION EASEMENTSPTE members may not use the Form 502CR to claim this credit.

1. Enter the portion of the total current-year conveyance amount, and any

carryover from prior year(s), attributable to each taxpayer . . . . . . . . . . . . . . . . . 1. 1.

2. Enter the amount of any payment received for the easement by each

taxpayer during 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. 2.

3. Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. 3.

4. Enter the amount from line 21 of Form 502; line 32c of Form 505; line 33 of

Form 515; line 13 of Form 504 or $5,000, whichever is less. See instructions . . . 4. 4.

5. Enter the lesser of line 3 or 4 here. (If you itemize deductions,

see Instruction 14.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. 5.

6. Total (Add amounts from line 5 for Taxpayers A and B.). Enter here and on Part K, line 6 . . . . . . . . . . . . . . . . 6.

7. Excess credit carryover. Subtract line 6 from the sum of lines 3A and 3B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.

Name of Institution(s)

Taxpayer A Taxpayer B

1500 00 1500 00

150075600A & C G

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16502C113

MARYLANDFORM


COM/RAD-012

2016Page 3

NAME SSN

PART G - HEALTH ENTERPRISE ZONE PRACTITIONER TAX CREDIT ** must attach required certification1. Credit (certified by the Department of Health and Mental Hygiene). Enter here and on Part K, line 7 . . . . . . . . . 1.

PART H – COMMUNITY INVESTMENT TAX CREDIT ** must attach required certification This credit is limited to individual taxpayers who have elected not to claim this credit on Form 500CR. If you have an Excess Carryover on Form

500CR attributable to any credit other than the Community Investment Tax Credit (CITC), you are not eligible to claim the CITC on Form 502CR.

You must use Form 500CR. Also, PTE members may not elect to use Form 502CR to claim the CITC.

1. Enter the amount of Excess CITC Carryover from Part X of your 2015 Form 500CR . . . . . . . . . . . . . . . . . . . . . . . . 1.

2. Amount of approved contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.

3. Enter 50% of line 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.

4. Enter the amount from line 3 or $250,000, whichever is less. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.

5. Add line 1 and line 4. Enter the result here and on Part K, line 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.

PART I – ENDOW MARYLAND TAX CREDIT **must attach required certificationThis credit is limited to individual taxpayers who have elected not to claim this credit on Form 500CR.

1. Enter the amount of Excess Endow Maryland Tax Credit Carryover from 2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.

2. Amount of approved donation to a qualified permanent endowment fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.

3. Enter 25% of line 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.

4. Enter the amount from line 3 or $50,000, whichever is less . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.

5. Add line 1 and line 4. Enter the result here and on Part K, line 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.

Note: Line 2 of Part I requires an addition to income. See Instruction 12.PART J – PRECEPTORS IN AREAS WITH HEALTH CARE WORKFORCE SHORTAGES TAX CREDIT **must attach required certification1. Physician Preceptorship Tax Credit: Enter amount certified by Department of Health and Mental Hygiene

(See Instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.

2. Nurse Practitioner Preceptorship Tax Credit: Enter amount certified by Department of Health and Mental Hygiene (See Instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.

3. Add line 1 and line 2. Enter the result here and on Part K, line 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.

PART K - INCOME TAX CREDIT SUMMARY1. Enter the amount from Part A, line 13 (If more than one state, see Instructions.) . . . . . . . . . . . . . . . . . . . . . . . . 1.

2. Enter the amount from Part B, line 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.

3. Enter the amount from Part C, line 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.

4. Enter the amount from Part D, line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.

5. Enter the amount from Part E, line 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.

6. Enter the amount from Part F, line 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.

7. Enter the amount from Part G, line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.

8. Enter the amount from Part H, line 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.

9. Enter the amount from Part I, line 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.

10. Enter the amount from Part J, line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.

11. Total (Add lines 1 through 10.) Enter this amount on line 24 of Form 502; line 14 of Form 504;

line 34 of Form 505 or line 35 of Form 515 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.

PART L – LOCAL INCOME TAX CREDIT SUMMARY1. Enter the amount from Part A, line 14 (If more than one state, see Instructions.) . . . . . . . . . . . . . . . . . . . . . . . . 1.

Enter this amount on line 31 of Form 502; line 19 of Form 504.

PART M- REFUNDABLE INCOME TAX CREDITS1. Neighborhood Stabilization Credit. Enter the amount and attach certification. . . . . . . . . . . . . . . . . . . . . . . . . . . 1.

2. Heritage Structure Rehabilitation Tax Credit (See Instructions for Form 502S). Attach certification(s). . . . . . . . . 2.

3. Refundable Business Income Tax Credit (See Instructions for Form 500CR.) You must file your return electronically to claim a business income tax credit.

4. IRC Section 1341 Repayment Credit. (See Instructions and Administrative Release 40.) Attach documentation . . 4.

5. Flow-through Nonresident PTE tax (See Instructions for required attachments.) . . . . . . . . . . . . . . . . . . . . . . . . 5.

6. Total. (Add lines 1 through 5.) Enter this amount on line 43 of Form 502, line 46 of Form 505

or line 51 of Form 515 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.

0

0

150075600A & C G

0

0

4196

4196

475

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16502C213

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.

. . . . . . . . . . . . . . . . . 10.

INSTRUCTIONS

If

return.

1.

3.

4.

7.

8.

2016

COM/RAD-006

MARYLAND FORM

IND PVPAYMENT VOUCHER

AG

150075600

CG

123040560


ROCKVILLE MD 20850

3381

E

502

16502M013

00

REV 01/27/17 PRO

' Cut Here '

FISCAL YEAR FILERS: BEGINNING MONTH:

Amount of payment

00

Daytime Phone Number

LOCALITY NO. FOR OFFICE USECheck if this is a new address. Check here if this is your first payment for

this taxable year.

2017 FORM 760ES - VoucherDoc ID 762 VIRGINIA ESTIMATED INCOME TAX PAYMENT VOUCHER FOR INDIVIDUALS

CALENDAR YEAR FILERS DUE:

our Social Security Number (SSN) Spouses SSN (if filing a joint return)Y

Mail your voucher and payment to the Virginia Department of Taxation, P. O. Box 1478, Richmond, VA 23218-1478, or see pages 7-8 and use the address listed for the city or county where you intend to file.

If you file with the Department, make your check payable to the Department of Taxation. If you file locally, make your check payable to your local Treasurer.

411.

05-01-17

A G150075600

C G

123040560


ROCKVILLE MD 20850

900

Mail 760ES Voucher 1 To:

Commissioner of the Revenue, P.O. Box 1478, Richmond, VA 23218-1478

REV 01/25/17 PRO 15551

1500756000 7621555 117056 900

' Cut Here '


Amount of payment

00



this taxable year.






411.

06-15-17


ROCKVILLE MD 20850

900

150075600 123040560


Treasurer, P.O. Box 1478, Richmond, VA 23218-1478

REV 01/25/17 PRO 15552

1500756000 7621555 117064 900

' Cut Here '


Amount of payment

00



this taxable year.






411.

09-15-17


ROCKVILLE MD 20850

900

150075600 123040560



REV 01/25/17 PRO 15553

1500756000 7621555 117099 900

' Cut Here '


Amount of payment

00



this taxable year.






411.

01-15-18


ROCKVILLE MD 20850

900

150075600 123040560



REV 01/25/17 PRO 15554

1500756000 7621555 118011 900

2016 Virginia Nonresident Income Tax ReturnDue May 1, 2017763

Enclose a complete copy of your federal tax return and all other required Virginia enclosures.

1 Adjusted Gross Income from federal return - Not federal taxable income........................................................... 1 00

2 Additions from Schedule 763 ADJ, Line 3. .......................................................................................................... 2 00

3 Add Lines 1 and 2. ............................................................................................................................................ 3 00

4 Age Deduction (See instructions and the Age Deduction Worksheet). ..................................................... YouEnter Birth Dates above. Enter Your Age Deduction on Line 4a and Your Spouse's Age Deduction on Line 4b.. .................................................................Spouse

4a 00

4b 00

5 Social Security Act and equivalent Tier 1 Railroad Retirement Act benefits reported on your federal return. .... 5 00

6 State income tax refund or overpayment credit reported as income on your federal return. .............................. 6 00

7 Subtractions from Schedule 763 ADJ, Line 7. ..................................................................................................... 7 00

8 Add Lines 4a, 4b, 5, 6 and 7.............................................................................................................................. 8 00

9 Virginia Adjusted Gross Income (VAGI). Subtract Line 8 from Line 3. ......................................................... 9 00

10 Itemized Deductions. See instructions. ............................................................................................................... 10 00

11 State and local income taxes claimed from federal Schedule A, if claiming itemized deductions. ...................... 11 00

12 If claiming itemized deductions subtract Line 11 from Line 10 or enter standard deduction amount. ................. 12 00

13 Exemption amount. Enter the total amount from the Exemption Sections 1 and 2 above. ................................. 13 00

14 Deductions from Schedule 763 ADJ, Line 9. ....................................................................................................... 14 00

15 Add Lines 12, 13, and 14. .................................................................................................................................. 15 00

16 Virginia Taxable Income computed as a resident. Subtract Line 15 from Line 9. ................................................ 16 00

17 Percentage from Nonresident Allocation Section on Page 2 (Enter to one decimal place only) ......................... 17 %

18 Nonresident Taxable Income. (Multiply Line 16 by percentage on Line 17). ....................................................... 18 00

19 Income Tax from Tax Table or Tax Rate Schedule ............................................................................................... 19 00

For Local Use

Page1

Va. Dept. of Taxation 2601044 Rev. 08/16 LTD $_________

First Name MI Last Name Suffix Your Social Security Number Check if deceased

Spouse's First Name (Filing Status 2 Only) MI Last Name Suffix Spouse's Social Security Number Check if deceased

Present Home Address (Number and Street or Rural Route) Your Birth Date(mm-dd-yyyy) - -

City, Town or Post Office State ZIP Code Spouse’s Birth Date(mm-dd-yyyy) - -

State of Residence Important - Name of Virginia City or County in which principal place of business, employment or income source is located.

City OR County

Locality Code

Check Applicable Boxes

Amended Return Check if Result of NOL

Name(s) or Address Different than Shown on 2015 VA Return

Overseas on Due Date

Dependent on Another’s Return Qualifying Farmer, Fisherman or Merchant Seaman

EIC Claimed on federal return

$___________________ .00 Filing Status Enter Filing Status Code in box below.

1 = Single. Federal head of household? YES 2 = Married, Filing Joint Return - both must have Virginia income3 = Married, Spouse Has No Income From Any Source4 = Married, Filing Separate Returns

Exemptions Add Sections 1 and 2. Enter the sum on Line 13.

Total Section 2

+ + + = X $800 =

Spouse 65 or over

You 65 or over

Spouse Blind

You Blind

+ + = X $930 =

Total Section 1DependentsSpouse if

Filing Status 2 or 3

You {Code If Filing Status 3 or 4, enter spouse's SSN in the Spouse's Social Security Number box at top of form and, enter Spouse’s Name_______________________________

1 2 1 8 1 9 7 9

0 1 2 0 1 9 8 5

196573

2 11 3 5 4650

196573

196573

6000

4650

10650

185923

46.1

85711

4671

A G 150-07-5600

C G 123-04-0560


ROCKVILLE MD 20850

900MD OUT OF STATE

1555 REV 01/25/17 PRO

2016 FORM 763 Page 2

I (We), the undersigned, declare under penalty provided by law that I (we) have examined this return and to the best of my (our) knowledge, it is a true, correct and complete return.

20a Your Virginia income tax withheld. Enclose Forms W-2, W-2G, 1099 and VK-1. .............................................. 20a 00

20b Spouse's Virginia income tax withheld. Enclose Forms W-2, W-2G, 1099 and VK-1. ....................................... 20b 00

21 2016 Estimated Tax Payments.. ......................................................................................................................... 21 00

22 2015 overpayment credited to 2016 estimated tax............................................................................................. 22 00

23 Extension Payment - submitted using Form 760IP. ............................................................................................ 23 00

24 Credit for Low-Income Individuals or Virginia Earned Income Credit from Schedule 763 ADJ, Line 17. ........... 24 00

25 Total credits from Schedule OSC. ...................................................................................................................... 25 00

26 Credit for Political Contributions ......................................................................................................................... 26 00

27 Credits from Schedule CR, Section 5, Line 1A................................................................................................... 27 00

28 Total payments and credits. Add Lines 20a through 27. ............................................................................. 28 00

29 If Line 19 is larger than Line 28, enter the difference. This is the INCOME TAX YOU OWE. ............................ 29 00

30 If Line 28 is larger than Line 19, enter the difference. This is the OVERPAYMENT AMOUNT. ......................... 30 00

31 Amount of overpayment on Line 30 to be CREDITED TO 2017 ESTIMATED INCOME TAX. .................................. 31 00

32 Virginia College Savings Plan Contributions from Schedule VAC, Part I, Line 6 ............................................... 32 00

33 Other Voluntary Contributions from Schedule VAC, Section II, Line 14 ............................................................. 33 00

34 Addition to Tax, Penalty and Interest from enclosed Schedule 763 ADJ, Line 21. ........................................... 34 0035 Sales and Use Tax is due on Internet, mail order, and out-of-state purchases (Consumer’s Use Tax).

See instructions. Do not leave blank. If you owe no sales and use tax, enter 00. ........................................... 35 00

36 Add Lines 31 through 35. ................................................................................................................................... 36 00

37 If you owe tax on Line 29, add Lines 29 and 36 - OR - If you have an overpayment on Line 30 and Line 36 is larger than Line 30, enter the difference. AMOUNT YOU OWE. Enclose payment or pay at www.tax.virginia.gov. .........Check here if paying by credit or debit card - See instructions. ....................................

37 00

38 If Line 30 is larger than Line 36, subtract Line 36 from Line 30. This is the amount to be REFUNDED TO YOU. 38 00

I (We) authorize the Dept. of Taxation to discuss this return with my (our) preparer. I agree to obtain my Form 1099-G at www.tax.virginia.gov.

Your Bank Routing Transit Number Your Bank Account Number Checking SavingsIf the Direct Deposit section below is not completed, your refund will be issued by check.DIRECT BANK DEPOSITDomestic Accounts OnlyNo International Deposits

Your Name Your SSN

Nonresident Allocation Percentage A - All Sources B - Virginia Sources1. Wages, salaries, tips, etc.. ................................................................................. 1 00 002. Interest income. ................................................................................................. 2 00 003. Dividends. .......................................................................................................... 3 00 004. Alimony received. .............................................................................................. 4 00 005. Business income or loss. ................................................................................... 5 00 006. Capital gain or loss/capital gain distributions..................................................... 6 00 007. Other gains or losses......................................................................................... 7 00 008. Taxable pensions, annuities and IRA distributions. ........................................... 8 009. Rents, royalties, partnerships, estates, trusts, S corporations, etc.................... 9 00 00

10. Farm income or loss. ......................................................................................... 10 00 0011. Other income. .................................................................................................... 11 00 0012. Interest on obligations of other states from Schedule 763 ADJ, Line 1. ............ 12 0013. Lump-sum and accumulation distributions included on Sch. 763 ADJ, Line 3. . 13 00 0014. TOTAL - Add Lines 1 through 13 and enter each column total here .................. 14 00 0015. Nonresident allocation percentage - Divide Line 14 B, by Line 14 A. Compute

percentage to one decimal place (e.g., 5.4%). Enter on Page 1, Line 17.. ....... 15 %

Your Signature Your Phone Number Date

Spouse’s Signature (If a joint return, both must sign) Spouse’s Phone Number Preparer’s PTIN Vendor Code

Preparer’s Name Firm’s Name (or Yours if Self-Employed) Preparer’s Phone Number Filing Election Code Office Use Only

00

196573 90652

196573 90652

46.1

3027

3027

1644

48

1692

48

A & C G 150-07-5600

1030 SELF-PREPARED

1555 REV 01/25/17 PRO

Avoid delays - If completed, submit Schedule 763 ADJ with Form 763

2016 Virginia Schedule 763 ADJ (Form 763 ADJ) Page 1

Your Name Your SSN

VA Dept. of Taxation 2601045 763ADJ Rev 06/16

Additions to Adjusted Gross Income

1. Interest on obligations of other states, exempt from federal income tax, but not from state tax. 1 00

2. Other additions to adjusted gross income. 002a. Fixed Date Conformity addition - See instructions ............................................................... 2a

2b - 2c. Refer to the Form 763 instructions for Other Addition Codes. 2b 2b

00

2c 2c00

3. Total Additions. Add Lines 1, 2a - 2c. Enter here and on Form 763, Line 2. .............................. 3 00

Subtractions from Adjusted Gross Income

4. Income (interest, dividends or gains) from obligations or securities of the U.S. exempt from state income tax, but not from federal tax .................................................................................. 4 00

5. Disability income reported as wages (or payments in lieu of wages) on your federal return. If claiming this subtraction you cannot also claim Age Deduction. Claim the one that benefits you most.

5a. Enter YOUR disability subtraction on 5a. ............................................................................ 5a 00

5b. Enter SPOUSE’s disability subtraction on 5b, if claiming Filing status 2 ............................ 5b 00

6. Other Subtractions as provided in instructions

6a. Fixed Date Conformity subtraction. See instructions............................................................ 6a 00

6b - 6d. Refer to the Form 763 instructions for Other Subtraction Codes. 6b. 6b

00

6c. 6c 00

6d. 6d 00

7. Total Subtractions. Add Lines 4, 5a, 5b, and 6a - 6d. Enter here and on Form 763, Line 7. ...... 7 00

Deductions from Virginia Adjusted Gross Income

8. Refer to the Form 763 instructions for Deduction Codes. 8a. 8a 00

8b. 8b 00

8c. 8c 00

9. Total Deductions. Add Lines 8a - 8c. Enter here and on Form 763, Line 14 .............................. 9 00

A & C G 150-07-5600

1555 REV 01/25/17 PRO

2016 Virginia Schedule 763 ADJ Page 2Your Name Your SSN

Tax Credit for Low-Income Individuals or Virginia Earned Income Credit - SEE INSTRUCTIONS

Family VAGI Name Social Security Number (SSN) Guideline Income

Yourself - - 00Spouse - - 00Dependent - - 00Dependent - - 00

10. If more than 4 exemptions, enclose schedule listing the name, SSN & VAGI. Enter total Family Guideline Income here. 10 00

11. Enter the total number of exemptions reported in the table above. Next, go to the Poverty Guidelines Table shown in the Form 763 instruction book for this Line to see if you qualify for this credit ........ 11

12. If you qualify, enter the number of personal and dependent exemptions reported on your Form 763 (see instructions). ....................................................................................................................... 12

13. Multiply Line 12 by $300. Enter the result on Line 13 and proceed to Line 14. If you do not qualify for the Tax Credit for Low-Income Individuals, but claimed an Earned Income Credit on your federal return, enter $0 and proceed to Line 14 ............................................................................................ 13

00

14. Enter the amount of Earned Income Credit claimed on your federal return. If you did not claim an Earned Income Credit on your federal return, enter $0 ..................................................................... 14 00

15. Multiply Line 14 by 20% (.20) ............................................................................................................ 15 0016. Enter the greater of Line 13 or Line 15 .............................................................................................. 16 0017. Compare the amount on Line 16 above to the amount of tax on Form 763, Line 19. Enter the lesser

of the two amounts here and on Form 763, Line 24. This is your credit amount. .............................. 17 00

Addition to Tax, Penalty and Interest

18. Addition to tax. Check if addition came from: ....... Form 760C Form 760F 18 00

19. Penalty.................................................................. Late Filing Penalty Extension Penalty 19 00 20. Interest (accrued on the tax you owe) ................................................................................................ 20 00 21. Total Addition to Tax, Penalty and Interest (add Lines 18 - 20). Enter here and on Form 763,

Line 34 ................................................................................................................................................ 21 00

A & C G 150-07-5600

48X

48

1555 REV 01/25/17 PRO

2016 Schedule INC/CGReport all W-2s, 1099s & VK-1s with VA Withholding

VA Account Number

Employer FEIN

Your/ Spouse SSN

VA Withholding

VA Wages, tips, other comp.

Total VA Withholding

You

Spouse

Total # of W-2s,1099s & VK-1s

SSN VA Withholding

WithholdingType

*VASINC116999*

To avoid delays - be sure to enter all information, including the Employer’s FEIN.

3027.150075600

01

A G

C G

150075600

150075600 W 3027. 223538509 30223538509F001 58537.

1555 REV 01/25/17 PRO

760C - 2016 Underpayment of Virginia Estimated Tax by Individuals, Estates and Trusts

• Attach this form to Form 760, 763, 760PY or 770.Fiscal Year Filers: Enter beginning date 20 , ending date 20 , and check here First Name, Middle Initial and Last Name (of Both If Joint) - OR - Name of Estate or Trust Your Social Security Number or FEIN

cIf Estate or Trust, Name and Title of Fiduciary Spouse's Social Security Number

Office Use SC Office Use Payment

cPart I - Compute Your Underpayment

1. 2016 Income Tax Liability After Spouse Tax Adjustment and Tax Credits. See instructions.(If $150 or less, you are not required to file Form 760C) 1.

2. Enter 90% of the Amount Shown on Line 1 2.

3. 2015 Income Tax Liability After Spouse Tax Adjustment and Tax Credits 3.

4. Enter the Amount From Line 2 or Line 3, Whichever is Less 4.

5. Enter the Number of Installment Periods for Which You Were Liable to Make Payments 5.

Line 6 Through 14: Complete Each Line Across All Columns Before Continuing to Next Line

A B C D6. Due Dates of Installment Payments May 1, 2016 June 15, 2016 Sept. 15, 2016 Jan. 15, 20177. Tax Liability

(Divide the amount on Line 4 by the number of installmentsreported on Line 5 and enter the result in the appropriatecolumns)

8. Enter the Income Tax Withheld for Each Installment Period

9. Enter the Overpayment Credit from Your 2015 Income TaxReturn

10. Enter the Amount of Any Timely Payment Made for EachInstallment Period in the Appropriate Column(Do not enter any late payments)

11. Underpayment or [Overpayment](Subtract Lines 8, 9 and 10 from Line 7. See instructions foroverpayment)

12. Other Payments(Enter the payments from the Late Payment/Overpayment Tablebelow, beginning with the earliest payment recorded. Do notenter more than the underpayment in any column.)

Date Amount

a. First Payment

b. Second Payment

c. Third Payment

d. Fourth Payment

13. Enter the Total Timely Payments Made as of Each InstallmentDue Date From Lines 8, 9, 10 and 12(For ex., in Column A enter all payments made by May 1, 2016)

14. Subtract Line 13 from Line 7(If the sum of all underpayments (do not include anyOVERPAYMENTS) reported is $150 or less, stop here; you arenot subject to an addition to tax. If your underpayments totalmore than $150, proceed to Part II)

Continued on Back gLate Payment/Overpayment Table (See Instructions for Lines 11 and 12.)

Date of Payment Date of Payment Date of Payment Date of Payment

Payment Amount $

Payment Amount$

Payment Amount$

Payment Amount $

VA

. Dep

t. of

Tax

atio

n 7

60C

26

0103

3 W

R

ev. 0

1/17

4

A & C G 150-07-5600

123-04-0560

4,671.

4,204.

7,689.

4,204.

1,051.

756.

295.

756.

295.

1,051.

757.

294.

757.

294.

1,051.

757.

294.

757.

294.

1,051.

757.

294.

757.

294.

REV 01/25/17 PRO 1555

760C - 2016Page 2

Part II - Exceptions That Void the Addition to Tax AMay 1, 2016

BJune 15, 2016

CSept. 15, 2016

DJan. 15, 2017

15. Total Amount Paid and Withheld from January 1, 2016 through theInstallment Date Indicated

16. Exception 1: Prior Year's Tax(Multiply the 2015 tax by the percentage in each col.)

100% of 2015 Tax 25% 50% 75% 100%

17. Exception 2: Tax on Prior Year's Income Using the2016 Rates and Exemptions(Multiply the 2015 tax by the percentage in each col.)

100% of Tax 25% 50% 75% 100%

18. Exception 3 Worksheet: Tax on Annualized 2016 Income (Use the formula below to compute the amount on lines 18a, b and c for each col.)Lines 18a, b and c: April 30 column: Multiply the actual amount for the period ended April 30, 2016, by 3.

May 31 column: Multiply the actual amount for the period ended May 31, 2016, by 2.4.August 31 column: Multiply the actual amount for the period ended August 31, 2016, by 1.5.

From January 1 to: April 30 May 31 August 31a. Annualized Virginia Adjusted Gross Income (VAGI) for Each Period Note

Estates and trusts should use end dates of March

31, April 30 & July 31.

b. Compute the Annualized Itemized Deductions Using the FormulaAbove OR Enter the Full Standard Deduction in Each Column if YouDid Not Claim Itemized Deductions

c. Compute the Annualized Child and Dependent Care Expenses andOther Deductions for Each Period

d. Total Dollar Amount of Exemptions Claimed on Your Returne. Virginia Taxable Income

(Subtract Lines 18b, c and d from Line 18a)f. Virginia Tax

(Enter the Virginia income tax for the amount(s) on line 18e)g. Multiply Line 18f by the Percentage Shown for Each Period 22.5% 45% 67.5%

NoteExceptions 3 and 4 do not apply to the fourth installment

period.

19. Exception 4 Worksheet: Tax on 2016 Income Over a 4, 5 and 8 Month Period* (* 3, 4 and 7 months for estates and trusts)From January 1 to: April 30 May 31 August 31

a. Enter Your Virginia Adjusted Gross Income (VAGI) for Each Periodb. Enter the Itemized Deductions Claimed for Each Period OR (If

Greater) the Full Standard Deductionc. Enter the Child and Dependent Care Expenses and Other

Deductions for Each Periodd. Enter the Total Dollar Amount of Exemptions Claimed on Your

Returne. Virginia Taxable Income

(Subtract Lines 19b, c and d from Line 19a)f. Virginia Tax

(Enter the Virginia income tax for the amount(s) on Line 19e)g. Multiply Line 19f by 90% (.90) for Each Period

Part III - Compute the Addition to TaxIf an exception has been met (Part II) for any installment period, complete the column for that period as follows: write "Exception" and the exception number (1, 2, 3, or 4) on Line 20; skip Lines 21 through 23; and enter "0" on Line 24. For all other periods, complete each line as instructed below.

AMay 1, 2016

BJune 15, 2016

CSept. 15, 2016

DJan. 15, 2017

20. Amount of Underpayment from Part I, Line 1421. Date of Payment from Part I, Line 12

(If no payments were entered on Line 12, enter the actual date ofpayment or May 1, 2017, whichever is earlier.)

22. Number of Days After Installment Due Date Through Date Paid or May1, 2017, Whichever Is Earlier (if May 1, 2017, is earlier, enter 365, 320, 228 and 106, respectively).

23. Multiply the Number of Days in Each Column on Line 22 by the DailyRate of .00016 (6% Per Annum)

24. Multiply the Amount on Line 20 by Line 23 for Each Column

25Addition to Tax (Total the amounts on Line 24. Enter here and on the "Addition to Tax" line on your income tax return)

c

7,689.

7,839.

48.

756.

1,922.

1,960.

295.

05/01/2017

365

0.05840

17.23

1,513.

3,845.

3,920.

294.

05/01/2017

320

0.05120

15.05

2,270.

5,767.

5,879.

294.

05/01/2017

228

0.03648

10.73

3,027.

7,689.

7,839.

294.

05/01/2017

106

0.01696

4.99

REV 01/25/17 PRO 1555

2016 Federal Tax ReturnForm 8879: IRS e-file Signature AuthorizationForm 1040: Individual Tax Return

2016 Maryland Tax ReturnForm 502DEP 1: Estimated Tax VoucherForm 502DEP 2: Estimated Tax VoucherForm 502DEP 3: Estimated Tax VoucherForm 502DEP 4: Estimated Tax VoucherForm EL101Form 502: Resident / Part Year Resident ReturnForm 502BForm 502CR: Personal Income Tax CreditsForm IND PV: Payment Voucher

2016 Virginia Tax ReturnForm 760-ES: Estimated Tax Voucher 1Form 760-ES: Estimated Tax Voucher 2Form 760-ES: Estimated Tax Voucher 3Form 760-ES: Estimated Tax Voucher 4Form 763: Nonresident Income Tax ReturnForm 763 ADJ: Virginia Schedule 763 ADJSchedule INC: Schedule of Withholding and IncomeForm 760 C: Underpayment of Estimated Tax

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