Test Scenario 9 TESTER R GRASS INDIANA 2010 Barcode TEST #9 2010 IT-40 Test Scenario 9 Taxpayer: TESTER R GRASS SSN: 400 02 4004 Spouse: MAY B GRASS SSN: 400 02 4005 Test Scenario 9 includes the following forms: Form IT 40 Schedule 1 Schedule 3 Schedule 4 Schedule 5 Schedule 6 Schedule 7 Schedule IT 2210 Schedule IN BAR Form W 2 Form 1099 R Indiana BC Test #9 Page 1 of 12 10/19/2010
Form IT-40 State Form 154 (R9 / 9-10) 2010 Indiana Full-Year Resident Individual Income Tax Return If fi ling for a fi scal year, enter the dates (see instructions) (MM/DD/YYYY): Due April 18, 2011 from to: Your Social Security Number Spouse s Social Security Number 400 02 4004 400 02 4005 Place X in box if applying for ITIN Your fi rst name Initial Last name TESTER R GRASS Place X in box if applying for ITIN Suffi x If fi ling a joint return, spouse s fi rst name Initial Last name MAY B GRASS Present address (number and street or rural route) 9 YINDINGQIAO HUTONG, XĪCHÉNG City State Zip/Postal code BEIJING JI 100000 Suffi x Place X in box if you are married fi ling separately. DRAFT 8/18/10 Foreign country 2-character code (see pg. XX) CH 6755 School corporation number (see pages XX and XX) Enter below the 2-digit county code numbers (found on the back of Schedule CT-40) for the county where you lived and worked on January 1, 2010. County where County where County where County where 67 you lived you worked 67 spouse lived 67 spouse worked 67 Round all entries 1. Enter your federal adjusted gross income (AGI) from your federal tax return (from Form 1040, line 37; Form 1040A, line 21; or from Form 1040EZ, line 4) Federal AGI 1 42450.00 2. Enter amount from Schedule 1, line 9, and enclose Schedule 1 Indiana Add-Backs 2.00 3. Add line 1 and line 2 3.00 4. Enter amount from Schedule 2, line 12, and enclose Schedule 2 Indiana Deductions 4.00 5. Subtract line 4 from line 3 Indiana Adjusted Income 5.00 6. You must complete Schedule 3. Enter amount from Schedule 3, line 5, and enclose Schedule 3 Indiana Exemptions 6 18000.00 7. Subtract line 6 from line 5 State Taxable Income 7.00 8. State adjusted gross income tax: multiply line 7 by 3.4% (.034) (if answer is less than zero, leave blank) 8 853.00 9. County tax. Enter county tax due from Schedule CT-40 (if answer is less than zero, leave blank) 9 376.00 10. Other taxes. Enter amount from Schedule 4, line 5 (enclose sch.) 10.00 11. Add lines 8, 9 and 10. Enter total here and on line 15 on the back Indiana Taxes 11.00 2032 626 43076 43076 25076 3261 15110111594 Indiana BC Test #9 Page 2 of 12 10/19/2010
12. Enter credits from Schedule 5, line 9 (enclose schedule) 12.00 13. Enter offset credits from Schedule 6, line 7 (enclose schedule) 13.00 14. Add lines 12 and 13 Indiana Credits 14.00 15. Enter amount from line 11 Indiana Taxes 15.00 16. If line 14 is equal to or more than line 15, subtract line 15 from line 14 (if smaller, skip to line 23) 16.00 17. Amount from line 16 to be donated to the Indiana Nongame Wildlife Fund 17.00 18. Subtract line 17 from line 16 Overpayment 18.00 650 150 800 3261 19. Amount from line 18 to be applied to your 2011 estimated tax account (see instructions on page XX). Enter your county code county tax to be applied a.00 Spouse s county code county tax to be applied b.00 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 18) 19d.00 DRAFT 8/18/10 20. Penalty for underpayment of estimated tax from Schedule IT-2210 or IT-2210A (enclose sch.) 20.00 21. Refund: Line 18 minus lines 19d and 20. Note: If less than zero, see line 23 instructions Your Refund 21.00 22. Direct Deposit (see page XX) 32 a. Routing Number b. Account Number c. Type: Checking Savings Hoosier Works MC d. Place an X in the box if refund will go to an account outside the United States 23. If line 15 is more than line 14, subtract line 14 from line 15. Add to this any amount on line 20 (see instructions on page XX) 23 2493.00 24. Penalty if fi led after due date (see instructions) 24.00 25. Interest if fi led after due date (see instructions) 25.00 26. Amount Due: Add lines 23, 24 and 25 Amount You Owe 26.00 No payment is due if you owe less than 1. Do not send cash. Please make your check or money order payable to: Indiana Department of Revenue. Credit card payers must see instructions. Sign and date this return after reading the Filing Authorization statement on Schedule 7. Enclose Schedule 7. Your Signature Date Spouse s Signature Date 2493 If enclosing payment mail to: Indiana Department of Revenue, P.O. Box 7224, Indianapolis, IN 46207-7224. Mail all other returns to: Indiana Department of Revenue, P.O. Box 40, Indianapolis, IN 46206-0040. 15110121594 Indiana BC Test #9 Page 3 of 12 10/19/2010
Schedule 1: Add-Backs Schedule 1 Form IT-40, State Form 53995 Instructions begin on page XX 2010 (R / 9-10) Enclosure Sequence No. 01 Name(s) shown on Form IT-40 Tester & May Grass Your Social Security Number 400 02 4004 Round all entries 1. Tax add back: certain taxes deducted from federal Schedules C, C-EZ, E and/or F 1.00 2. Net operating loss carryforward from federal Form 1040, Other income line 2.00 3. Income taxed on federal Form 4972 (lump sum distribution) 3.00 4. Domestic production activities add-back 4.00 5. Bonus depreciation add-back 5.00 6. Section 179 expense excess add-back 6.00 7. Unemployment compensation add-back. Important: see instructions on page XX. 626 DRAFT 7/30/10 Enter the amount of unemployment compensation from Box 1 of Form 1099G(s) Box A.00 Enter the amount of unemployment compensation reported on Form 1040, line 19, Form 1040A, line 13, or Form 1040EZ, line 3 Box B.00 Subtract Box B from Box A, enter total here 7.00 8. Other Add-Backs: See instructions beginning on page XX a. Enter add-back name code no. 8a.00 b. Enter add-back name code no. 8b.00 c. Enter add-back name code no. 8c.00 d. Enter add-back name code no. 8d.00 e. Enter add-back name code no. 8e.00 f. Enter add-back name code no. 8f.00 g. Enter add-back name code no. 8g.00 h. Enter add-back name code no. 8h.00 i. Enter add-back name code no. 8i.00 j. Enter add-back name code no. 8j.00 9. Add lines 1 through 8. Enter total here and on Form IT-40, line 2 Total Indiana Add-Backs 9.00 626 22810111594 Indiana BC Test #9 Page 4 of 12 10/19/2010
Schedule 3: Exemptions Schedules 3 & 4 Form IT-40, State Form 53997 2010 (R / 9-10) 03 TESTER & MAY GRASS.00.00 400 02 4004 Round all entries 8 8000 6 9000 DRAFT 8/6/10.00 1 1000.00 18000 Total Exemptions.00 Schedule 4: Other Taxes.00.00.00.00 Total Other Taxes.00 32 2000 2032 Indiana BC Test #9 Page 5 of 12 10/19/2010
Schedule 5: Credits Schedule 5 Form IT-40, State Form 53998 Instructions begin on page XX (R / 9-10) 2010 Enclosure Sequence No. 04 Name(s) shown on Form IT-40 TESTER & MAY GRASS Your Social Security Number 400 02 4004 Round all entries 1. Indiana state tax withheld: enclose W-2s, 1099s showing state tax withholding amounts 1.00 2. Indiana county tax withheld: enclose W-2s, 1099s showing county tax withholding amounts 2.00 3. Estimated tax paid for 2010: include any extension payment made with Form IT-9 3.00 4. Unifi ed tax credit for the elderly 4.00 5. Earned income credit: enclose Schedule IN-EIC and enter amount from Section A, line A-2 5.00 6. Lake County residential income tax credit 6.00 7. Economic development for a growing economy credit 7.00 8. Media production expenditure credit 8.00 40 10 600 DRAFT 7/30/10 9. Add lines 1 through 8. Enter total here and on Form IT-40, line 12 Total Credits 9.00 650 23110111594 Indiana BC Test #9 Page 6 of 12 10/19/2010
Schedule 6: Offset Credits Schedule 6 Form IT-40, State Form 53999 Instructions begin on page XX (R / 9-10) 2010 Enclosure Sequence No. 05 Name(s) shown on Form IT-40 Your Social Security Number TESTER & MAY GRASS 400 02 4004 1. Credit for local taxes paid outside Indiana 1.00 2. County credit for the elderly: attach federal Schedule R 2.00 3. 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-40, line 9 (see Combined Limitation instructions) Round all entries 4. College credit: attach Schedule CC-40 4.00 DRAFT 7/30/10 5. Credit for taxes paid to other states: enclose other state s return 5.00 6. Other Credits: See instructions (enclose additional sheets if necessary) EMPLOYER HLTH BENFT PLAN 842 150 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-40, line 8 (see Combined Limitation instructions) 7. Add lines 1 through 6. Enter total here and on line 13 of Form IT-40 Total Offset Credits 7.00 150 23210111594 Indiana BC Test #9 Page 7 of 12 10/19/2010
Schedule 7: Additional Required Information Schedule 7 Form IT-40, State Form 54000 Instructions begin on page XX (R / 9-10) 2010 Enclosure Sequence No. 06 Name(s) shown on Form IT-40 Your Social Security Number TESTER & MAY GRASS 400 02 4004 1. Federal filing information Are you fi ling a federal income tax return for 2010? Place X in appropriate box. Yes No 2. Out-of-state income Complete if you and/or your spouse (if fi ling a joint return) received any salary, wage, tip and/or commission income from Illinois, Kentucky, Michigan, Ohio, Pennsylvania or Wisconsin. Enter two-digit code number from the back of Schedule CT-40 for state where you and/or your spouse worked. State where you worked Your income State where spouse worked Spouse s income.00.00 3. Extension of time to file a. Place X in box if you have fi led a federal extension of time to fi le, Form 4868. 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. 4. 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-2210. DRAFT 8/6/10 5. Date of death If any individual listed at the top of the IT-40 died during 2010, enter date of death (MM/DD) (see instructions on page XX). Taxpayer s date of death 2010 Spouse s date of death 2010 Authorization Sign Form IT-40 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. 6. Your daytime telephone number Your e-mail address I authorize the Department to discuss my return with my personal representative (see page XX). Paid Preparer: Firm s Name (or yours if self-employed) Yes No If yes, complete the information below. Personal Representative s Name (please print) Telephone number Address City IN-OPT on fi le with paid preparer if not fi ling electronically Federal I.D. Number PTIN OR Social Security No. Address City State Zip Code State Zip Code 23310111594 Indiana BC Test #9 Page 8 of 12 10/19/2010
1229 150 1079 971 50 1029 1800 971 TESTER & MAY GRASS 400 02 4004 243 243 243 242 13 13 13 11 150 150 150 150 163 163 163 161 80 80 80 81 321 32 Indiana BC Test #9 Page 9 of 12 10/19/2010
Schedule IN-BAR State Form 54083 (R / 9-10) Schedule IN-BAR: Barcode 2010 Enclosure Sequence No. 20 Name(s) shown on Form IT-40, IT-40EZ, IT-40PNR or IT-40RNR TESTER & MAY GRASS Your Social Security Number 400 02 4004 Designate the form with which Schedule IN-BAR is being fi led: 1. IT-40 2. IT-40EZ 3. IT-40PNR 4. IT-40RNR Space Required for Barcode: 3.45 X 1.76 2010 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. Special mailing address when enclosing Schedule IN-BAR Mail your tax return to: Indiana Department of Revenue P.O. Box 7231 Indianapolis, IN 46207-7231 24310111594 Indiana BC Test #9 Page 10 of 12 10/19/2010
22222 b Employer identification number (EIN) c Employer s name, address, and ZIP code a Employee s social security number 400-02-4004 OMB No. 1545-0008 1 Wages, tips, other compensation 2 Federal income tax withheld 35-2585258 24500 500 GREEN GROWERS 100 MEADOW LN GREENCASTLE, IN 46135 3 Social security wages 4 Social security tax withheld 24500 1519 5 Medicare wages and tips 6 Medicare tax withheld 24500 355 7 Social security tips 8 Allocated tips d Control number e Employee s first name and initial Last name Suff. TESTER R GRASS 200 S VINE ST GREENCASTLE, IN 46135-1668 9 Advance EIC payment 10 Dependent care benefits 11 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 o d e 12b C o d e 12c C o d e 12d C o d e 1000 IN 000352585258 24500 40 24500 10 67 Form W-2 Wage and Tax Statement 2010 Department of the Treasury Internal Revenue Service Copy 1 For State, City, or Local Tax Department Indiana BC Test #9 Page 11 of 12 10/19/2010
VOID CORRECTED PAYER S name, street address, city, state, and ZIP code 1 Gross distribution SNODGRASS FEED AND SEED 17500 1 PLANTATION ST 2a Taxable amount GREENCASTLE IN 46402 17500 2b Taxable amount not determined PAYER S federal identification number Street address (including apt. no.) City, state, and ZIP code Account number (see instructions) RECIPIENT S identification number 1st year of desig. Roth contrib. 3 Capital gain (included in box 2a) OMB No. 1545-0119 2010 35-5689124 400-02-4005 550 RECIPIENT S name MAY B GRASS 200 S VINE ST GREENCASTLE IN 46135-1668 Form 1099-R 5 Employee contributions /Designated Roth contributions or insurance premiums 7 Distribution code(s) IRA/ SEP/ SIMPLE 9a Your percentage of total distribution % 10 State tax withheld Form 1099-R Total distribution 4 Federal income tax withheld 6 Net unrealized appreciation in employer s securities 8 Other Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc. Copy 1 For State, City, or Local Tax Department % 9b Total employee contributions 11 State/Payer s state no. 12 State distribution 0 IN/000277777001 17500 14 Name of locality 15 Local distribution 0 PUTNAM 17500 Department of the Treasury - Internal Revenue Service 13 Local tax withheld Indiana BC Test #9 Page 12 of 12 10/19/2010