Oklahoma Resident Income Tax Return

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0 0 0 0 0 0 0 0 0 0 0 0 0 0 Oklahoma Resident Income Tax Return Security Number Spouse s Social Security Number (joint return only) Name and Address Please Print or Type Filing Status Part One: To Arrive at Oklahoma Adjusted Gross Income If you are not required to file, see page of the Packet. If line is different than line, enclose a copy of your Federal return. 0 Federal adjusted gross income (from Federal 00, 00A, or 00EZ).. Oklahoma Subtractions (enclose Schedule -A)................... Line minus line............................................ Out-of-state income, except wages. Describe (a) (Enclose Federal schedule with detailed description; see instructions) Line minus line b............................................ Oklahoma Additions (enclose Schedule -B)...................... Oklahoma adjusted gross income (line plus line )................ Part Two: Oklahoma Taxable Income, Tax and Credits Oklahoma Standard Deduction: Single or Married Filing Separate: $,0 Married Filing Joint or Qualifying Widow(er): $, Head of Household: $, Itemized Deductions: Enclose copy of the Federal Schedule A. ## Your first name, middle initial and last name If a joint return, spouse s first name, middle initial and last name Mailing address (number and street, including apartment number, rural route or PO Box) City, State and Zip Place an X in this box if this taxpayer is deceased Place an X in this box if this taxpayer is deceased Single Married filing joint return (even if only one had income) Married filing separate If spouse is also filing, list SSN and name in box: Head of household with qualifying person Qualifying widow(er) with dependent child Please list the year spouse died in box at right: Age or Over? (Please see instructions) Yourself Spouse Not Required to File Place an X in this box if you do not have sufficient gross income to require you to file a Federal return. (see instructions) 0 0 0 0 0 0 0 0 Exemptions Yourself Spouse Regular Number of dependent children Number of other dependents Add the Totals from the boxes. Write the Total in the box below. Total Note: If you may be claimed as a dependent on another return, enter 0 for your regular exemption. Round to Nearest Whole Dollar STOP AND READ: If line b is zero, complete lines 0-. If line b is more than zero, see Schedule -D and do not complete lines 0-. Oklahoma Taxable Income (line minus line )................... Oklahoma Income Tax from Tax Table (see pages 0- of instructions) If using Farm Income Averaging, enter tax from Form, line and enter a in box. If paying the Health Savings Account additional 0% tax, add additional tax here and enter a in box. STOP AND READ: If line is equal to or larger than line, complete line. If line is smaller than line, complete Schedule -E. Oklahoma Adjustments (enclose Schedule -C)................... Oklahoma income after adjustments (line minus line ).............. Oklahoma standard deduction or Federal itemized deductions.......... Exemptions ($,0 x total number of exemptions claimed above)........ Total deductions and exemptions (add lines 0 and or amount from Sch. -D, line ). Oklahoma child care/child tax credit (see instructions)................ Credit for taxes paid to another state (enclose Form TX)............ Form - 0 * NOTE: If claiming Special Exemption, see instructions on page of Packet. Form CR - Other Credits Form. List CR line number claimed here.. Income Tax (line minus lines -) Do not enter less than zero.... DO NOT PAY THIS AMOUNT. PAYMENT IS FIGURED ON LINE. + * // Special + Blind + + b 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Form - Resident Income Tax Return - Page on Form : Part Three: Tax, Credits and Payments Total from line... For use tax table, see page of the Packet. Enclose all W-s, 0s or other withholding statements. See back of Form -S or Packet for further information. Use tax due on Internet, mail order, or other out-of-state purchases... 0 If you certify that no use tax is due, place an X here Business Activity Tax (enclose Form -BAT)... Balance (add lines, 0 and )... Oklahoma withholding... 0 estimated tax payments (qualified farmer )... 0 payment with extension... Low Income Property Tax Credit (enclose Form -H)... Sales Tax Relief Credit (enclose Form -S)... Oklahoma Earned Income Credit (see instructions) (If line is equal to or more than line, complete line. If line is smaller than line, complete Schedule -F. If you are not required to file, see Not Required to File on page of the Packet for instructions)... Total payments and credits (add lines -)... Part Four: Refund 0 If line is more than line, subtract line from line. This is your overpayment.. 0 Amount of line 0 to be applied to 0 estimated tax. For further information regarding estimated tax, see page of the Packet. Donations from your refund (total from Schedule -G). Total deductions from refund (add lines and )... Amount to be refunded to you (line 0 minus line )... Part Five: Amount You Owe If you have an underpayment of estimated tax (line ) & overpayment (line 0), see instructions. Under penalty of perjury, I declare the information contained in this document, and all attachments and schedules, is true and correct to the best of my knowledge and belief. Taxpayer s signature Taxpayer s occupation Daytime Phone (optional) ## 0 Schedule -G provides you with the opportunity to make a financial gift from your refund to a variety of Oklahoma organizations. Please place the line number of the organization from Schedule -G in the box below. If you give Direct Deposit Note: to more than one organization, put a in the box. Enclose Schedule -G. For Direct Deposit Information see the Packet. If you do not have your refund deposited directly into your bank account, you will receive a debit card. For debit card information see All About Refunds in the Packet. 0 Is this refund going to or through an account that is located outside of the United States? Yes No Deposit my refund in my: Date checking account savings account Spouse s signature Spouse s occupation Daytime Phone (optional) Routing Number: Account Number: If line is more than line, subtract line from line. This is your tax due... Donation: Eastern Red Cedar Revolving Fund... $ $ $ Donation: Public School Classroom Support Fund... $ $ $ Underpayment of estimated tax interest (annualized installment method )... For delinquent payment (add penalty of % plus interest at.% per month).. Total tax, donation, penalty and interest (add lines -)... 0 Place an X in this box if the Oklahoma Tax Commission may discuss this return with your tax preparer... Do not staple documentation to this form. To attach items, please use a paper clip. Mailing Address for this form: P.O. Box, Oklahoma City, OK -0 The Oklahoma Tax Commission is not required to give actual notice to taxpayers of changes in any state tax law. 0 0 0 0 0 0 0 0 Date Paid Preparer s PTIN Paid Preparer s signature Paid Preparer s address and phone number // Date 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Form - Resident Income Tax Return - Page NOTE: Enclose this page ONLY if you have an amount shown on a schedule. on Form : 0 ## Schedule -A Oklahoma Subtractions Interest on U.S. government obligations... Social Security benefits taxed on your Federal Form 00 or 00A... Federal civil service retirement in lieu of social security... Retirement Claim Number: Taxpayer Schedule -B State and municipal bond interest... Out-of-state losses (describe ) Enter as a positive number. Lump sum distributions (not included in your Federal Adjusted Gross Income)... Federal net operating loss - Enter as a positive number... Recapture of depletion claimed on a lease bonus or add back of excess Federal depletion... Expenses incurred to provide child care programs... Recapture of Contributions to Oklahoma College Savings Plan and OklahomaDream Account(s)... Miscellaneous: Other additions (enter number in box for type of addition)... Total additions (add lines -, enter total here and on line of Form )... Schedule -C 0 0 0 0 0 0 0 0 Spouse Military Retirement (see instructions for limitation)... Oklahoma government or Federal civil service retirement (see instructions for limitation)... Other retirement income... U.S. Railroad Retirement Board benefits... // Oklahoma depletion... Oklahoma net operating loss... Exempt tribal income... Gains from the sale of exempt government obligations... Oklahoma Capital Gain Deduction (enclose Form )... Miscellaneous: Other subtractions (enter number in box for type of deduction). Total subtractions (add lines -, enter total here and on line of Form )... Oklahoma Additions Oklahoma Adjustments Military pay exclusion - Active Duty, Reserve and National Guard (not retirement income)... Qualifying disability deduction... Political contributions (limited to $ [$ for joint return])... Interest qualifying for exclusion (limited to $ [$ for joint return])... Qualified adoption expense... Contributions to Oklahoma College Savings Plan and OklahomaDream Account(s)... Miscellaneous: Other adjustments (enter number in box for type of deduction) Total adjustments (add lines -, enter total here and on line of Form )... qualifications and required enclosures. 0 qualifications and required enclosures. qualifications and required enclosures. 0 0 0 0 0 0

0 0 0 0 0 0 0 0 ## 0 Form - Resident Income Tax Return - Page NOTE: Enclose this page ONLY if you have an amount shown on a schedule. on Form : Schedule -D Deductions and Exemptions 0 0 qualifications and required enclosures. Use this schedule if you have income from out-of-state (Form, line ). Your exemptions and deductions must be prorated on the ratio of Oklahoma Adjusted Gross Income to Federal Adjusted Gross Income reduced by allowable adjustments except out-of-state income. If you do not have out-of-state income on Form, line, do not use this schedule. Instead complete Form, lines 0-. Oklahoma standard deduction or Federal itemized deductions claim... Exemptions ($,0 x number of exemptions claimed at top of Form )... Total (add lines and )... Divide the amount on line of Form by the amount on line of Form 0 0 Enter the percentage from the above calculation here (do not enter more than %)... % Total allowable deductions and exemptions (multiply line by percentage on line, enter total here and on line of Form ) (Leave lines 0 and of Form blank)... Schedule -E Child Care/Child Tax Credit 0 qualifications and required enclosures. If your Federal Adjusted Gross Income is $,0 or less and you are allowed either a credit for child care expenses or the child tax credit on your Federal return, you are allowed a credit against your Oklahoma tax. Your Oklahoma credit is the greater of: 0% of the credit for child care expenses allowed by the IRS Code. Your allowed Federal credit cannot exceed the amount of your Federal tax reported on your Federal return. 0 or % of the child tax credit allowed by the IRS Code. This includes both the nonrefundable child tax credit and the refundable additional child tax credit. The credit must be prorated based on the ratio of Oklahoma Adjusted Gross Income to Federal Adjusted Gross Income. If your Federal Adjusted Gross Income is greater than $,0, no credit is allowed. Enclose a copy of your Federal return and, if applicable, the Federal child care credit schedule. Enter your Federal child care credit... Multiply line by 0%... Enter your Federal child tax credit // 0 0 (total of child tax credit & additional child tax credit)... Multiply line by %... Enter the larger of line or line... Divide the amount on line of Form by the amount on line of Form Enter the percentage from the above calculation here (do not enter more than %)... Multiply line by line. This is your Oklahoma child care/child tax credit. Enter total here and on Form, line... 0 0 Schedule -F Earned Income Credit qualifications and required enclosures. You are allowed a credit equal to % of the Earned Income Credit allowed on your Federal return. The credit must be prorated on the ratio of Oklahoma Adjusted Gross Income to Federal Adjusted Gross Income. Enclose a copy of your Federal return. If you are not required to file, see Not Required to File on page of the Packet for instructions. Federal earned income credit... Multiply line by %... Divide the amount on line of Form by the amount on line of Form 0 0 Enter the percentage from the above calculation here (do not enter more than %)... % Oklahoma earned income credit... (multiply line by line, enter total here and on line of Form ) 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Form - Resident Income Tax Return - Page NOTE: Enclose this page ONLY if you have an amount shown on a schedule. on Form : This schedule allows you to make a donation from your refund to a variety of Oklahoma organizations. Information regarding each program, their mission, how funds are utilized, and their mailing address are shown in Schedule -G Information. If you are not receiving a refund, but would like to make a donation to one of these organizations, Schedule -G Information lists the mailing address to mail your donation to the organization. If you are not receiving a refund and wish to donate to the Eastern Red Cedar Revolving Fund or the Public School Classroom Support Fund, please see line or of Form. Place an X in the box associated with the dollar amount you wish to have deducted from your refund and donated to that organization. Then carry that figure over into the column at the right. When you carry your figure back to line of Form, please list the line number of the organization to which you donated. If you donate to more than one organization, please write a in the box at line of Form. 0 ## Schedule -G Oklahoma Wildlife Diversity Program... $ $ $... Low Income Health Care Fund... $ $ $... Oklahoma Breast and Cervical Cancer Fund... $ $ $... Support of Programs for Volunteers to Act as Court Appointed Special Advocates for Abused or Neglected Children... $ $ $... Oklahoma Pet Overpopulation Fund... $ $ $... Support of the Oklahoma National Guard... $ $ $... Oklahoma Leukemia and Lymphoma Fund... $ $ $... Support of Programs for Regional Food Banks in Oklahoma... $ $ $... Support of Folds of Honor Scholarship Program $ $ $... Y.M.C.A. Youth and Government Program... $ $ $.. 0 Multiple Sclerosis Society Fund... $ $ $.. Support Oklahoma Honor Flights... $ $ $.. Eastern Red Cedar Revolving Fund... $ $ $.. Support of Domestic Violence and Sexual Assault Services... $ $ $.. Support of Volunteer Fire Departments... $ $ $.. Oklahoma Lupus Revolving Fund... $ $ $.. Oklahoma Sports Eye Safety Program... $ $ $.. Historic Greenwood District Music Festival Fund... $ $ $.. Public School Classroom Support Fund... $ $ $.. 0 Total donations (add lines -, enter total here and on line of Form )... 0 Schedule -G: Information - Oklahoma Wildlife Diversity Program The Oklahoma Wildlife Diversity Program is funded primarily by concerned Oklahomans. All donations provide for a variety of projects, including research on Texas horned lizards and other rare wildlife, wildlife observation activities, such as statewide educational workshops, informational brochures and posters, and management of a bat cave purchased with previous program donations. If you are not receiving a refund, you may still support Oklahoma wildlife by sending a donation to: Wildlife Diversity Program, 0 North Lincoln, Oklahoma City, OK 0. - Low Income Health Care Fund Oklahomans helping each other is what the Indigent (Low Income) Health Care Fund is all about. Donations made to the fund are used to help provide medical and dental care for needy children and families. Every dollar you donate goes directly for health care costs. If you are not receiving a refund, you may contribute toward indigent health care by sending a donation to: Oklahoma Department of Human Services, Revenue Processing Unit, Re: Indigent Health Care Revolving Fund, P.O. Box, Oklahoma City, OK. // Donations from Refund 0 0 0 0 0 0 0 0 - Oklahoma Breast and Cervical Cancer Fund You may donate for the benefit of breast and cervical cancer early detection, public education and research. Your donation will be placed in a fund to be used for the purpose of funding programs to increase knowledge of breast and cervical cancer risk and prevention and provide mammograms, pap tests and biopsies for low-income women. If you are not receiving a refund, you may still donate. Mail your contribution to: Oklahoma State Department of Health, Breast and Cervical Cancer Revolving Fund, 0 NE 0th Street, Oklahoma City, OK. - Support for Programs for Volunteers to Act as Court Appointed Special Advocates for Abused or Neglected Children You may donate from your tax refund to support programs for volunteers to act as Court Appointed Special Advocates for abused or neglected children. Donations will be placed in the Income Tax Checkoff Revolving Fund for Court Appointed Special Advocates. Monies will be expended by the Office of the Attorney General for the purpose of providing grants to the Oklahoma CASA Association. If you are not receiving a refund, you may still donate. Mail your contribution to: Oklahoma CASA Association, Inc., P.O. Box, Oklahoma City, OK. 0 0 0 0 0 0

0 Form - Resident Income Tax Return - Page NOTE: Do NOT enclose this page with Form. Schedule -G: Information - continued - Oklahoma Pet Overpopulation Fund You may donate from your tax refund for the benefit of the Oklahoma Pet Overpopulation Fund. Monies placed in this fund will be expended for the purpose of developing educational programs on pet overpopulation and for implementing spay/neuter efforts in this state. If you are not receiving a refund, you may still donate. Mail your contribution to: Oklahoma Department of Agriculture, Food and Forestry, Animal Industry Division, North Lincoln Blvd., Oklahoma City, OK 0. - Support of the Oklahoma National Guard You have the opportunity to donate from your tax refund for the benefit of providing financial relief to qualified members of the Oklahoma National Guard and their families. Donations will be placed in the Income Tax Checkoff Revolving Fund for the Support of the Oklahoma National Guard Relief Program. Monies, to assist Oklahoma National Guard members and their families with approved hardship expenses, will be expended by the Military Department. If you are not receiving a refund, you may still donate. Please mail your contribution to: Operation Homefront Task Force, 0 Military Circle, Oklahoma City, OK -. - Oklahoma Leukemia and Lymphoma Fund You have the opportunity to donate from your tax refund for the benefit of the Oklahoma Leukemia and Lymphoma Revolving Fund. Monies from the fund will be used by the State Department of Health for the purpose of supporting voluntary health agencies dedicated to curing Leukemia, Lymphoma, Hodgkin s Disease, and Myeloma and to improving the quality of life of patients and their families. If you are not receiving a refund, you may still donate. Please mail your contribution to: State Department of Health, Oklahoma Leukemia and Lymphoma Revolving Fund -, P.O. Box, Oklahoma City, OK -. - Support of Programs for Regional Food Banks in Oklahoma You may donate from your tax refund for the benefit of the Regional Food Bank of Oklahoma and the Community Food Bank of Eastern Oklahoma (Oklahoma Food Banks). The Oklahoma Food Banks are the largest hunger-relief organizations in the state - distributing food to charitable and faith-based feeding programs throughout all counties in Oklahoma. Your donation will be used to help provide food to the more than,0 Oklahomans at risk of hunger on a daily basis. If you are not receiving a refund, you may still donate by mailing your contribution to: Oklahoma Department of Human Services, Revenue Processing Unit, Re: Programs for OK Food Banks, P.O. Box, Oklahoma City, OK. - Support of Folds of Honor Scholarship Program You have the opportunity to donate from your tax refund to support the Folds of Honor Foundation. Folds of Honor is a 0(c)() charitable organization that provides post-secondary educational scholarships for children and spouses of military service men and women killed or disabled while serving in the war in Iraq or Afghanistan. If you are not receiving a refund, you may still donate. Mail your contribution to: Folds of Honor Foundation, North Patriot Drive, Owasso, OK 0. 0- Y.M.C.A. Youth and Government Program You have the opportunity to donate from your tax refund for the benefit of the Oklahoma chapter of the Y.M.C.A. Youth and Government program. Monies donated will be expended by the State Department of Education for the purpose of providing grants to the Program so young people may be educated regarding government and the legislative process. If you are not receiving a refund, you may still donate. Mail your contribution to: Oklahoma State Department of Education, Y.M.C.A. Youth and Government Program, Office of the Comptroller, North Lincoln Boulevard, Room, Oklahoma City, OK 0-. - Multiple Sclerosis Society Fund You may donate for the benefit of research toward a cure for Multiple Sclerosis. Your donation will be placed in a fund for the purpose of providing grants to the Multiple Sclerosis Society for purposes of mobilizing people and resources to drive research for a cure and to address the challenges of everyone affected by multiple sclerosis. If you are not receiving a refund, you may still donate. Mail your contribution to: Oklahoma State Department of Health, Multiple Sclerosis Society Revolving Fund, P.O. Box, Oklahoma City, OK -. // - Support Oklahoma Honor Flights You have the opportunity to donate any amount of your tax refund to support Oklahoma Honor Flights. Oklahoma Honor Flights is a 0(c)() notfor-profit organization that transports Oklahoma World War II veterans to Washington, D.C. to visit the memorial dedicated to honor their service and sacrifice. If you are not receiving a refund, you may still donate. Mail your contribution to: Oklahoma Honor Flights, P.O. Box 0, Midwest City, OK 0. - Eastern Red Cedar Revolving Fund Help stimulate rural development, improve public health and enhance wildlife habitat by donating to the Eastern Red Cedar Revolving Fund. The Fund was established to promote the harvesting and utilization of eastern red cedar trees and to promote the marketing, research and education efforts concerning the tree and eastern red cedar products. Monies donated may be expended by the State Board of Agriculture as directed by the Eastern Red Cedar Registry Board. You can also mail a contribution to: Eastern Red Cedar Revolving Fund, Oklahoma Department of Agriculture, Food and Forestry, North Lincoln Boulevard, Oklahoma City, OK 0. - Support of Domestic Violence and Sexual Assault Services You may donate from your tax refund for the benefit of domestic violence and sexual assault services in Oklahoma that have been certified by the Attorney General. Your donation will be used to provide grants to domestic violence and sexual assault service providers for the purpose of providing domestic violence and sexual assault services in Oklahoma. The term services includes but is not limited to programs, shelters or a combination thereof. If you are not receiving a refund, you may still donate. Mail your contribution to: Attorney General, Domestic Violence and Sexual Assault Services Fund, NE st Street, Oklahoma City, OK 0. - Support of Volunteer Fire Departments You may donate from your tax refund for the benefit of volunteer fire departments in Oklahoma. Your donation will be used to provide grants to volunteer fire departments in this state for the purpose of purchasing bunker gear, wildland gear and other protective clothing. If you are not receiving a refund, you may still donate. Mail your contribution to: Oklahoma State Fire Marshal, Attn: Volunteer Fire Department Fund, 0 NW rd Street, Suite, Oklahoma City, OK 0. - Oklahoma Lupus Revolving Fund You may donate from your refund for the benefit of the Oklahoma Lupus Revolving Fund. Monies from the fund will be used by the State Department of Health to provide grants to the Oklahoma Medical Research Foundation for the purpose of funding research into treating and curing lupus in this state. If you are not receiving a refund, you may still donate. Mail your contribution to: State Department of Health, Lupus Revolving Fund, P.O. Box, Oklahoma City, OK -. - Oklahoma Sports Eye Safety Program You may donate from your refund for the benefit of the Oklahoma Sports Eye Safety Program. Your donation will be used by the State Department of Health to establish a sports eye safety grant program for the purchase and distribution of sports eye safety programs and materials to Oklahoma classrooms and sports eye safety protective wear to children age and under. Monies will also be used to explore opportunities to utilize nonprofit organizations to provide such safety information or equipment. If you are not receiving a refund, you may still donate. Mail your contribution to: State Department of Health, Sports Eye Safety Fund, P.O. Box, Oklahoma City, OK -. - Historic Greenwood District Music Festival Fund With part of your tax refund you can support music festivals in the Historic Greenwood District of Tulsa. Your donation will be used by the Oklahoma Historical Society to assist with music education, public concerts, and a celebration of Tulsa s and Oklahoma s musical heritage. You may also mail your contributions to: Greenwood District Music Festival Fund, Oklahoma Historical Society, Nazih Zuhdi Dr., Oklahoma City, OK 0. - Public School Classroom Support Fund Donations to the Public School Classroom Support Revolving Fund will be used by the State Board of Education to provide one or more grants annually to public school classroom teachers. Grants will be used by the classroom teacher for supplies, materials, or equipment for the class or classes taught by the teacher. Grant applications will be considered on a statewide competitive basis. You may also mail a donation to: Oklahoma State Board of Education, Public School Classroom Support Fund, Office of the Comptroller, North Lincoln Boulevard, Room, Oklahoma City, OK 0-.

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