INDIANA 2012 Barcode TEST # IT-40PNR

Transcription

1 Test Scenario 10 TEST R WATERS INDIANA 2012 Barcode TEST # IT-40PNR Test Scenario 10 Taxpayer: TEST R WATERS SSN: Test Scenario 10 includes the following forms: Form IT 40PNR Schedule A Schedule B Schedule C Schedule D Schedule F Schedule G Schedule H Schedule CT 40PNR Schedule IN BAR 2 Form W 2 Form 1099 G (Issued by Indiana Department of Workforce Development) Form 1099 R Form WH 18 **New Indiana BC Test 10 Page 1 of 19 10/19/2012

2 Form IT-40PNR State Form 472 (R11 / 9-12) If fi ling for a fi scal year, enter the dates (see instructions) (MM/DD/YYYY): from Indiana Part-Year or Full-Year Nonresident Individual Income Tax Return 2012 to: Due April 15, 2013 Your Social Security Number Spouse s Social Security Number Place X in box if applying for ITIN Your fi rst name Initial Last name TEST R WATERS If fi ling a joint return, spouse s fi rst name Initial Last name Place X in box if applying for ITIN Suffi x Suffi x Present address (number and street or rural route) Place X in box if you are 301 OCEAN DRIVE married fi ling separately. City State Zip/Postal code KEY BISCAYNE FL DRAFT 9/5/12 Foreign country 2-character code (see pg. 6 ) School corporation number (see pages 58 and 59 ) Enter below the 2-digit county code numbers (found on the back of Schedule CT-40PNR) for the county where you lived and worked on January 1, County where you lived County where you worked County where spouse lived County where spouse worked Round all entries 1. Complete Schedule A fi rst. Enter here the amount from Section 3, line 37B, and enclose Schedule A Indiana Income Enter amount from Schedule B, line 6, and enclose Schedule B Indiana Add-Backs Add line 1 and line Enter amount from Schedule C, line 12, and enclose Schedule C Indiana Deductions Subtract line 4 from line 3 Indiana Adjusted Income You must complete Schedule D. Enter amount from Schedule D, line 7, and enclose Schedule D Indiana Exemptions Subtract line 6 from line 5 State Taxable Income State adjusted gross income tax: multiply line 7 by 3.4% (.034) (if answer is less than zero, leave blank) County tax. Enter county tax due from Schedule CT-40PNR (if answer is less than zero, leave blank) Other taxes. Enter amount from Schedule E, line 4 (enclose sch.) Add lines 8, 9 and 10. Enter total here and on line 16 on the back Indiana Taxes Indiana BC Test 10 Page 2 of 19 10/19/2012

3 12. Enter credits from Schedule F, line 8 (enclose schedule) Enter offset credits from Schedule G, line 7 (enclose schedule) Automatic Taxpayer Refund credit Enter XXX if joint fi ling but only one is eligible (leave blank if not eligible; see instructions on page XX ) Add lines 12, 13 and 14 Indiana Credits Enter amount from line 11 Indiana Taxes If line 15 is equal to or more than line 16, subtract line 16 from line 15 (if smaller, skip to line 24) Amount from line 17 to be donated to the Indiana Nongame Wildlife Fund Subtract line 18 from line 17 Overpayment Amount from line 19 to be applied to your 2013 estimated tax account (see instructions on page 10 ). Enter your county code county tax to be applied a.00 Spouse s county code county tax to be applied b DRAFT 9/5/12 Indiana adjusted gross income tax to be applied c.00 Total to be applied to your estimated tax account (a + b + c; cannot be more than line 19) 20d Penalty for underpayment of estimated tax from Schedule IT-2210 or IT-2210A (enclose sch.) Refund: Line 19 minus lines 20d and 21. Note: If less than zero, see line 24 instructions Your Refund Direct Deposit (see page 11 ) c. Type: Checking Savings Hoosier Works MC a. Routing Number b. Account Number d. Place an X in the box if refund will go to an account outside the United States 24. If line 16 is more than line 15, subtract line 15 from line 16. Add to this any amount on line 21 (see instructions on page 11 ) Penalty if fi led after due date (see instructions) Interest if fi led after due date (see instructions) Amount Due: Add lines 24, 25 and 26 Amount You Owe Do not send cash. Please make your check or money order payable to: Indiana Department of Revenue. Sign and date this return after reading the Authorization statement on Schedule H. You must enclose Schedule H. Your Signature Date Spouse s Signature Date If enclosing payment mail to: Indiana Department of Revenue, P.O. Box 7224, Indianapolis, IN Mail all other returns to: Indiana Department of Revenue, P.O. Box 40, Indianapolis, IN Indiana BC Test 10 Page 3 of 19 10/19/2012

4 Schedule A Form IT-40PNR State Form (R11 / 9-12) Name(s) shown on Form IT-40PNR Schedule A Section 1: Income or Loss (Complete Proration, Section 2 and Section 3 on back) 2012 Your Social Security Number TEST R WATERS Sequence No. 01 Page 1 of 2 Section 1: Income or (Loss) Enter in Column A the same income or loss you reported on your 2012 federal income tax return, Form 1040, 1040A or 1040EZ (except for line 19B and/or a net operating loss carryforward on line 20B; see instructions). Round all entries. Line-by-line instructions begin on page 13. Column A Income from Federal Return Column B Income Taxed by Indiana 1. Your wages, salaries, tips, commissions, etc 1A B Spouse s wages, salaries, tips, commissions, etc 2A.00 2B Taxable interest income 3A B Dividend income 4A B Taxable refunds, credits, or offsets of state and local taxes from your federal return 5A B Alimony received 6A B DRAFT 9/5/12 7. Business income or loss from federal Schedule C or C-EZ _ 7A B Capital gain or loss from sale or exchange of property from your federal return 8A B Other gains or (losses) from Form A B Total IRA distribution 10A.00 10B Total pensions and annuities 11A B Net rent or royalty income or loss reported on federal Schedule E 12A B Income or loss from partnerships 13A B Income or loss from trusts and estates 14A B Income or loss from S corporations 15A B Farm income or loss from federal Schedule F 16A B Unemployment compensation 17A B Taxable Social Security benefi ts 18A B Indiana apportioned income from Schedule IT-40PNRA 19B Other income reported on your federal return 20A B List source(s). (Do not include federal net operating loss in Column B. See instructions on page 15.) 21. Subtotal: add lines 1 through A B Indiana BC Test 10 Page 4 of 19 10/19/2012

5 Schedule A Schedule A Proration; Form IT-40PNR Section 2: Adjustments to Income 2012 Sequence No. 01A Page 2 of 2 Proration Section See instructions on page C. Note: Nonresident military personnel see special instructions on page 15. and complete worksheet. 21C.00 21D. For all other individuals, divide the amount on line 21B by the amount on line 21A (see instructions if either line 21A and/or 21B are less than zero). Please round your answer to a decimal followed by three numbers. Example: 3,100 8,000 =.3875, which rounds to.388 (do not enter a number greater than 1.00). Enter result here and on Schedule D, line 6 21D. 398 Section 2: Adjustments to Income Note: Enter in Column A only those deductions claimed on your 2012 federal income tax return, Form 1040, 1040A or 1040EZ. Round all entries. Line-by-line instructions continue on page 16. Column A Federal Adjustments Column B Indiana Adjustments DRAFT 9/5/ Educator expenses (see instructions) 22A Certain business expenses of reservists, performing artists, etc 23A B Health savings account deduction 24A B Moving expenses (see instructions on page 16 ) 25A B Deductible part of self-employment tax 26A.00 26B Self-employed, SEP, SIMPLE, and qualifi ed plans 27A.00 27B Self-employed health insurance deduction 28A.00 28B Penalty on early withdrawal of savings 29A.00 29B Alimony paid 30A B IRA deduction 31A.00 31B Student loan interest deduction (see instructions) 32A.00 32B Tuition and fees deduction (see instructions) 33A Domestic production activities deduction 34A Other (see instructions) 35A B Add lines 22 through 35 36A B Section 3: Totals 37. Subtract line 36 from line 21 of Section 1. Carry amount from line 37B to Form IT-40PNR, line 1 37A B Indiana BC Test 10 Page 5 of 19 10/19/2012

6 Schedule B: Add-Backs Schedule B Form IT-40PNR, State Form Instructions begin on page (R3 / 9-12) Sequence No. 02 Name(s) shown on Form IT-40PNR Your Social Security Number TEST R WATERS Tax add back: certain taxes deducted from federal Schedules C, C-EZ, E and/or F Income taxed on federal Form 4972 (lump sum distribution) Bonus depreciation add-back Section 179 expense excess add-back Other Add-Backs: See instructions beginning on page 18. Round all entries DEFERRAL OF BUS INDEBTED a. Enter add-back name code no. 5a.00 RESTAURANT PROPERTY b. Enter add-back name code no. 5b.00 RETAIL IMPROVE PROPERTY c. Enter add-back name code no. 5c DRAFT 5/21/12 DISASTER ASSIST PROPERTY d. Enter add-back name code no. 5d.00 REFINERY PROPERTY e. Enter add-back name code no. 5e.00 FILM OR TV PRODUCTION f. Enter add-back name code no. 5f.00 PREFERRED STOCK g. Enter add-back name code no. 5g.00 PRINCIPLE RESIDENCE EXCL h. Enter add-back name code no. 5h.00 OTHER i. Enter add-back name code no. 5i.00 ENVIRONMENT REMED j. Enter add-back name code no. 5j.00 OOS MUNICIPAL OBLIG INT k. Enter add-back name code no. 5k.00 MTRSPRTS ENTERTAIN CPLX l. Enter add-back name code no. 5l.00 RIC DIVDND NON-RES ALIENS m. Enter add-back name code no. 5m.00 OIL GAS WELL DPLTION n. Enter add-back name code no. 5n.00 o. Enter add-back name code no. 5o Add lines 1 through 5. Enter total here and on Form IT-40PNR, line 2 Total Indiana Add-Backs Indiana BC Test 10 Page 6 of 19 10/19/2012

7 Schedule C: Deductions Schedule C Form IT-40PNR, State Form Instructions begin on page (R3 / 9-12) Sequence No. 03 Name(s) shown on Form IT-40PNR 1. Renter s deduction Indiana address where rented if different from the one on the front page (enter below) Your Social Security Number TEST R WATERS Landlord s name and address (enter below) Amount of rent paid.00 Round all entries Number of months rented Enter the lesser of 3,000 or amount of rent paid Homeowner s residential property tax deduction Address where property tax was paid if different from front page (enter below) 110 E MAIN ST, CARMEL IN Number of months lived there 3 Amount of property tax paid Enter the lesser of 2,500 or the amount of Indiana property tax paid 2.00 DRAFT 5/21/12 3. State tax refund reported on federal return Interest on U.S. government obligations Taxable Social Security benefi ts Taxable railroad retirement benefi ts Military service deduction: 5,000 maximum for qualifying person Non-Indiana locality earnings deduction: 2,000 maximum per qualifying person Insulation deduction: 1,000 maximum Nontaxable portion of unemployment compensation (from Unemployment Comp. Worksheet) Other Deductions: See instructions (attach additional sheets if necessary) a. Enter deduction name code no. 11a.00 b. Enter deduction name code no. 11b.00 c. Enter deduction name code no. 11c Add lines 1 through 11. Enter total here and on line 4 of Form IT-40PNR. Total Deductions Indiana BC Test 10 Page 7 of 19 10/19/2012

8 Schedule D: Exemptions Schedules D & E Form IT-40PNR, State Form (Schedule E begins after line 7 below) 2012 (R3 / 9-12) Sequence No. 04 Name(s) shown on Form IT-40PNR Your Social Security Number TEST R WATERS Number of exemptions claimed on your federal return x If you did not claim an exemption on your federal return, enter 1 in the box above. See instructions on page 28 if you did not fi le a federal return. 2. Claim an additional exemption for certain dependent children (see instructions). Enter number you are eligible to claim x 1500: you MUST enclose Schedule IN-DEP Place X in box(es) below if, by December 31, 2012 Round all entries You were age 65 or older Spouse was 65 or older and/or blind and/or blind Total number of boxes with Xs x DRAFT 9/5/12 4. If age 65 or older, enter amount from Schedule A, line 37A If this amount is less than 40,000, place X in box(es) below if: You were age 65 or older Spouse was 65 or older Total number of boxes with Xs x Add lines 1, 2, 3 and Enter the number from Schedule A, Proration Section, line 21D Multiply line 5 by line 6. Enter here and on Form IT-40PNR, line 6 Total Exemptions 7.00 Schedule E: Other Taxes Instructions begin on page Use tax on out-of-state purchases from line 4 of Sales/Use Tax Worksheet Household employment taxes. Enclose Schedule IN-H Recapture of Indiana s CollegeChoice 529 credit. Enclose Schedule IN-529R Add lines 1 through 3. Enter here and on Form IT-40PNR, line 10. Total Other Taxes Indiana BC Test 10 Page 8 of 19 10/19/2012

9 Schedule F: Credits Schedule F Form IT-40PNR, State Form Instructions begin on page 30 (R3 / 9-12) 2012 Sequence No. 05 Name(s) shown on Form IT-40PNR Your Social Security Number TEST R WATERS Indiana state tax withheld: enclose W-2s, 1099s, WH-18s showing state tax withholding amounts Indiana county tax withheld: enclose W-2s, 1099s, WH-18s showing county tax withholding amts Estimated tax paid for 2012: include any extension payment made with Form IT Unifi ed tax credit for the elderly Earned income credit: see instructions on page 31 Enter earned income credit from Schedule IN-EIC, line A-3 Box A.00 Round all entries Enter number from Schedule A, Proration Section, line 21D Box B. Multiply Box A by Box B, enter total here 5.00 DRAFT 9/5/12 6. Lake County residential income tax credit Economic development for a growing economy credit Add lines 1 through 7. Enter total here and on Form IT-40PNR, line 12 Total Credits Indiana BC Test 10 Page 9 of 19 10/19/2012

10 Schedule G: Offset Credits Schedule G Form IT-40PNR, State Form Instructions begin on page 43 (R3 / 9-12) 2012 Sequence No. 06 Name(s) shown on Form IT-40PNR Your Social Security Number TEST R WATERS Credit for local taxes paid outside Indiana County credit for the elderly: attach federal Schedule R Other Local Credits: See instructions (enclose additional sheets if necessary) a. Enter credit name code no. 3a.00 b. Enter credit name code no. 3b.00 Important: Lines 1 through 3 cannot be greater than the county tax due on Form IT-40PNR, line 9 (see Combined Limitation instructions) Round all entries COMM ENHANCE DIST CRED VOLUN REMEDIATION CRED College credit: attach Schedule CC DRAFT 5/21/12 5. Credit for taxes paid to other states: enclose other state s return Other Credits: See instructions (enclose additional sheets if necessary) COAL COMBUST CRED a. Enter credit name code no. 6a.00 b. Enter credit name code no. 6b.00 c. Enter credit name code no. 6c.00 d. Enter credit name code no. 6d.00 Important: Lines 4 through 6 added together cannot be greater than the state adjusted gross income tax due on Form IT-40PNR, line 8 (see Combined Limitations instructions) 7. Add lines 1 through 6. Enter total here and on line 13 of Form IT-40PNR Total Offset Credits Indiana BC Test 10 Page 10 of 19 10/19/2012

11 Schedule H Form IT-40PNR State Form (R3 / 9-12) Name(s) shown on Form IT-40PNR Section 1: Residency Information Schedule H Section 1: Residency Information (Complete Section 2: Additional Information on back) 2012 Your Social Security Number TEST R WATERS Example State of Residence Date From (MM/DD) List all state(s)and dates of your (and your spouse s, if fi ling jointly) residency during Enter 2-letter state name (e.g. IL for Illinois) or the letters OC if you were a resident of a foreign country. Instructions begin on page 52. Date To (MM/DD) Sequence No. 07 Page 1 of 2 Did you fi le a tax return with the state/country? Place X in appropriate box. IL Yes X No IN Yes X No Your information (a) (b) State of Date From Residence (MM/DD) (c) Date To (MM/DD) Did you fi le a tax return with the state/country? Place X in appropriate box. DRAFT 9/5/12 1A IN Yes No 1B FL Yes No 1C Yes No 1D Yes No Spouse s information if married filing jointly (a) (b) (c) State of Date From Date To Residence (MM/DD) (MM/DD) Did you fi le a tax return with the state/country? Place X in appropriate box. 2A Yes No 2B Yes No 2C Yes No 2D Yes No Turn over to complete Section Indiana BC Test 10 Page 11 of 19 10/19/2012

12 Schedule H Form IT-40PNR State Form (R3 / 9-12) Schedule H Section 2: Additional Required Information Instructions begin on page Sequence No. 07A Page 2 of 2 Section 2: Additional Information 1. Federal filing information Are you fi ling a federal income tax return for 2012? Place X in appropriate box. Yes No 2. Extension of time to file a. Place X in box if you have fi led a federal extension of time to fi le, Form b. Place X in box if you have fi led an Indiana extension of time to fi le, Form IT-9, or online via epay. 3. Farm / Fishing income Place X in box if at least two-thirds of your gross income was made from farming or fi shing. Important: If you placed an X in the box, you MUST attach Schedule IT Date of death If any individual listed at the top of the IT-40PNR died during 2012, enter date of death (MM/DD). Taxpayer s date of death 2012 Spouse s date of death 2012 DRAFT 9/5/12 Authorization Sign Form IT-40PNR after reading the following statement. Under penalty of perjury, I have examined this return and all attachments and to the best of my knowledge and belief, it is true, complete and correct. I understand that if this is a joint return, any refund will be made payable to us jointly and each of us is liable for all taxes due under this return. Also, my request for direct deposit of my refund includes my authorization to the Indiana Department of Revenue to furnish my fi nancial institution with my routing number, account number, account type and Social Security number to ensure my refund is properly deposited. I give permission to the Department to contact the Social Security Administration to confi rm that the Social Security number(s) used on this return is correct T10PNR@GMAIL.COM 5. Your daytime telephone number Your address I authorize the Department to discuss my return with my personal representative (see page 52 ). Yes No If yes, complete the information below. Personal Representative s Name (please print) SONNY BEACH Telephone number Address City State S SHORELINE DR KEY BISCAYNE FL Zip Code Paid Preparer: Firm s Name (or yours if self-employed) CHESTER TAXMAN IN-OPT on fi le with paid preparer if not fi ling electronically PTIN P Address City State 1322 N MAIN ST KEY BISCAYNE FL Zip Code Indiana BC Test 10 Page 12 of 19 10/19/2012

13 Schedule CT-40PNR Form IT-40PNR, State Form (R12 / 9-12) County Tax Schedule for Part-Year and Full-Year Indiana Nonresidents 2012 Sequence No. 8 Name(s) shown on Form IT-40PNR Your Social Security Number TEST R WATERS Lake County Residents: Turn to the Special Instructions for Lake County residents on page 56 if you and/or your spouse lived and/ or worked in Lake County, Ind., on Jan. 1, If you determine that Lake County tax is due, fi nd your and/or spouse s 4-digit code number (see page 57 ) and enter it here. Your Lake County 4-digit number Spouse s Lake County 4-digit number SECTION 1: To be completed by those taxpayers who were residents of a county that had adopted a county income tax. 1. Enter the amount from IT-40PNR, line 7. Note: If both you and your spouse lived in the same county on January 1 (or lived in the same Lake County location on January 1), enter the entire amount from Form IT-40PNR, line 7 on line 1A only. Column A - Yourself Column B - Spouse s See instructions on page 54 1A B If you claimed a non-indiana locality earnings deduction on Schedule C, line 8, enter the amount here. If not, leave blank _ 2A.00 2B.00 DRAFT 9/5/12 3. Add lines 1 and 2 3A B Enter the resident rate from the county tax chart on the back of this schedule for the county where you lived on Jan. 1, A. 01 4B. 5. Multiply line 3 by the rate on line 4 5A B Add lines 5A and 5B. Enter the total here. Note: Perry County residents: If you live in Perry County and worked in the Kentucky counties of Breckinridge, Hancock or Meade, you must complete lines 7 and 8. Otherwise, enter the total here and on line 9 below (see page 55 ) Enter the amount of income that was taxed by any of the Kentucky counties listed on line 6 above Multiply line 7 by.0056 and enter total here Enter total of line 6 minus line 8. Continue with Section 2 below if you are married fi ling jointly and you/spouse need to complete it. Otherwise, enter this amount on line 9 of Form IT-40PNR SECTION 2: To be completed by those taxpayers who, on Jan. 1, 2012, were residents of a county that had not adopted an Indiana county income tax, but worked in an Indiana county that had adopted a county income tax. Column A - Yourself Column B - Spouse s 1. Enter your principal employment income. See page 55 for further Section 2 instructions 1A.00 1B Enter deductions. See page 56 for the complete list of allowable deductions and further instructions 2A.00 2B Subtract line 2 from line 1 3A.00 3B Enter some or all of the exemptions from line 7 of Schedule D (see instructions on page 56 ) 4A.00 4B Subtract line 4 from line 3 5A.00 5B Enter the nonresident rate from the chart on the back of this schedule for the county where you worked on Jan. 1, A. 6B. 7. Multiply the income on line 5 by the rate on line 6 7A.00 7B Enter total of 7A plus 7B; carry to Form IT-40PNR, line 9. (If you have an amount on Section 1, line 9 above, combine that with the amount on line 8 and enter total on Form IT-40PNR, line 9) Indiana BC Test 10 Page 13 of 19 10/19/2012

14 Schedule IN-BAR State Form (R3 / 9-12) Schedule IN-BAR: Barcode 2012 Sequence No. 20 Name(s) shown on Form IT-40, IT-40EZ, IT-40PNR or IT-40RNR Your Social Security Number TEST R WATERS Designate the form with which Schedule IN-BAR is being fi led: 1. IT IT-40EZ 3. IT-40PNR 4. IT-40RNR B1 Space Required for Barcode: 3.45 X INDIANA Barcode Datasheet Enclose Schedule IN-BAR as the last schedule. Example. If fi ling an IT-40, Schedule 2, Schedule 3 and Schedule 7, place Schedule IN-BAR behind Schedule 7. Do NOT fi le this page alone. B2 Space Required for Barcode: 3.45 X 1.76 B3 Space Required for Barcode: 3.45 X Indiana BC Test 10 Page 14 of 19 10/19/2012

15 22222 b Employer identification number (EIN) c Employer s name, address, and ZIP code SCUBA JOE'S 444 S SHORELINE DR KEY BISCAYNE FL a Employee s social security number OMB No Wages, tips, other compensation 2 Federal income tax withheld Social security wages 4 Social security tax withheld Medicare wages and tips 6 Medicare tax withheld Social security tips 8 Allocated tips d Control number 9 10 Dependent care benefits e Employee s first name and initial Last name Suff. TEST R WATERS 301 OCEAN DRIVE KEY BISCAYNE FL Nonqualified plans 12a C 13 Statutory employee 14 Other f Employee s address and ZIP code 15 State Employer s state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name Retirement plan Third-party sick pay IN o d e 12b C o d e 12c C o d e 12d C o d e Wage and Tax Form W-2 Copy 1 For State, City, or Local Tax Department Statement 2012 Department of the Treasury Internal Revenue Service Indiana BC Test 10 Page 15 of 19 10/19/2012

16 22222 b Employer identification number (EIN) c Employer s name, address, and ZIP code a Employee s social security number OMB No Wages, tips, other compensation 2 Federal income tax withheld Social security wages 4 Social security tax withheld INDIANA GOVT ENTITY 22 REVENUE ST LEOPOLD IN Medicare wages and tips 6 Medicare tax withheld 7 Social security tips 8 Allocated tips d Control number 9 10 Dependent care benefits e Employee s first name and initial Last name Suff. TEST R WATERS 301 OCEAN DRIVE KEY BISCAYNE FL Nonqualified plans 12a C 13 Statutory employee f Employee s address and ZIP code 15 State Employer s state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name IN Other Retirement plan Third-party sick pay o d e 12b C o d e 12c C o d e 12d C o d e Wage and Tax Form W-2 Copy 1 For State, City, or Local Tax Department Statement 2012 Department of the Treasury Internal Revenue Service Indiana BC Test 10 Page 16 of 19 10/19/2012

17 VOID CORRECTED PAYER S name, street address, city, state, and ZIP code 1 Gross distribution MY PENSION PLAN 1199 N MERIDIAN ST INDIANAPOLIS IN PAYER S federal identification number RECIPIENT S name RECIPIENT S identification number TEST R WATERS 2a Taxable amount 2b Taxable amount not determined 3 Capital gain (included in box 2a) 60 5 Employee contributions /Designated Roth contributions or insurance premiums OMB No Form 1099-R Total distribution 4 Federal income tax withheld 6 Net unrealized appreciation in employer s securities Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc. Copy 1 For State, City, or Local Tax Department Street address (including apt. no.) 7 Distribution IRA/ 8 Other code(s) SEP/ SIMPLE 301 OCEAN DRIVE % City, state, and ZIP code 9a Your percentage of total 9b Total employee contributions KEY BISCAYNE FL distribution % 10 Amount allocable to IRR 11 1st year of desig. Roth contrib. 12 State tax withheld 13 State/Payer s state no. 14 State distribution within 5 years IN/ Account number (see instructions) 15 Local tax withheld 16 Name of locality 17 Local distribution HAMILTON 60 Form 1099-R Department of the Treasury - Internal Revenue Service Indiana BC Test 10 Page 17 of 19 10/19/2012

18 CONFIDENTIAL RECORD PURSUANT TO IC , IC CORRECTED (if checked) PAYERS name, address, zip code OMB No and federal identifying number: This is important tax information and is FORM 1099-G being furnished to the Internal Revenue Indiana Department of Workforce Development 201 CERTAIN Service. If you are required to file a Benefit Administration Section return, a negligence penalty or other GOVERNMENT 10 N Senate Avenue sanction may be imposed on you if this PAYMENTS Indianapolis, IN income is taxable and the IRS determines that it has not been reported. FEDERAL I.D. # THIS IS ONLY AN INFORMATION STATEMENT. THIS IS NOT A BILL OR NOTICE OF REFUND. RECIPIENTS Identifying number Box 1 UNEMPLOYMENT Box 2 UNEMPLOYMENT Box 3 BOX 2 AMOUNT Box 4 FEDERAL INCOME COMPENSATION YOU REPAID IS FOR TAX YEAR TAX WITHHELD Please retain this form in your tax records. The Internal Revenue Service has been informed by our agency of the amounts shown on the form. The box 1 amount was not reduced to reflect benefits repaid to your claim. See IRS filing instructions for filing. RECIPIENTS name, address, zip code TEST R WATERS 301 OCEAN DRIVE KEY BISCAYNE FL Additional Instructions If you have any questions regarding this form, please contact Social Security number is required so as to locate your claim file. Instructions for Recipient Box 1. -Shows the total unemployment compensation paid to you this year. This amount is taxable income by you. For details, see the instructions for your Federal income tax return. If you expect to receive these benefits next year, see Form 1040-ES for estimated tax payments. Box 2. -Shows the amount repaid by you during the year. If this repayment relates to an amount listed in Box 1, it can be subtracted from the amount in Box 1 when you file your return. See IRS filing instructions. Box 3. -Shows the tax year for which the refund, credit or offset was made. See IRS filing instructions. Box 4. -Shows the amount of Federal Tax withheld during the year. Indiana BC Test 10 Page 18 of 19 10/19/2012

19 INDIANAPOLIS PARTNERS, LTD 100 N SENATE AVE INDIANAPOLIS, IN TEST R WATERS 301 OCEAN DRIVE KEY BISCAYNE, FL , Indiana BC Test 10 Page 19 of 19 10/19/2012