administrative hearing - missourii missouri department of revenue 2009 form m0-1040 'zj/...

BEFORETHE' ADMINISTRATIVE HEARING COMMISSION'

STATE OF MISSOURI FILED DOUGLAS ELLIS, )

) ) ) ) ) ) ) ) )

MAY 1 3 2014

ADMINISTRATIVE HEARING COMMISSION

Petitioner,

V. Case No. 13-2080 RS

DIRECTOR OF REVENUE,

Respondent,

NOTICE OF EVIDENCE TO BE OFFERED AT HEARING

Respondent, Acting Director of Revenue ("Director"), states that in order to facilitate a

hearing by telepresence, the Director is providing notice to the Commission of the evidence the

Director may offer - Exhibit A through D if necessary.

WHEREFORE, based upon the foregoing, Respondent prays that the Commission accept

this Notice of Evidence to be Offered at Hearing.

Respectfully submitted,

Trevor Bossert General Counsel Department of Revenue

Maria A. Sanders, Missoun·"ntl~UJ..:lt.Z.Q.88~2~ Associate Counsel Missouri Department of Revenue Truman State Office Bldg. 301 West High, Room 670 P.O. Box 475 Jefferson City, MO 65105-0475 Phone (573) 751-0961 Fax (573) 751-7151

Attorney for Respondent.

CERTIFICATE OF SERVICE

I hereby certify that a true and correct copy of the foregoing was mailed, postage prepaid, on May 13, 2014, to:

Douglas Ellis 7904 E. 12i11 Ter Grandview, MO 64030

2

t?i MISSOURI DEPARTMENT OF REVENUE 2009 FORM M0-1040 'ZJ/ INDIVIDUAL INCOME TAX RETURN-LONG FORM FOR CALENDAR YEAR JAN. 1-DEC. 31, 2009, OR FISCAL YEAR BEGINNING

Select Month ENDING Select Month Select Ye. 11'•.11'11:INll::11•:1:::11.11:~

NAME AND ADDRESS 'SOFTWARE ~

VENDOR CODE I • ' • 1111\11

Exhibit A

'" . '- L . YI . .. • ,,u. ... .. .. .~ ---·~1· SOCIAL SECURITY NUIR I SPOUSE'S SOCIAL SECURITY NUMBER •.,'; ~IM'J.1 i';!'1 ~~~I l IIIJ"1 .~ ~ 419

~ ,

f~ ,• lo iii'~ I :t_' ,

u ~J, ~; ,I I '~ ~ NAME (LAST) (FIRST) M.I. JA,SR •.:~ .,f ~ T, ~ ,., ., N' ~ ,•~ , 0 ;~. ·f. I • ,• ,r ly"

ELLIS DOUGLAS M owo, i r,-' iO :aft ~

~g ~~ , ,,,. .i : .: h L&'

SPOUSE'S (LAST) (FIRST) MJ JR, SR llJC\I ·-ijl' I"' ""I II Oz I ' .r' D~-IN CARE OF NAME (ATIOANEY, EXECUTOR, PERSONAL REPRESENTATIVE, ETC.) COUNTY OF RESIDENCE SCHOOL DISTRICT NO.

JACKSON GRANDVIEW C-4 (JAO

PRESENT ADDRESS (INCLUDE APARTMENT NUMBER OR AURAL ROUTE) CITY, TOWN, OR POST OFFICE STATE ZIP CODE 7904 E 127TH TERRACE GRANDVIEW MO 64030

You may contri~ute to any one or all of the I

Children's £f veterans

I Elderly Horne I Missouri e Workers' @ Childhood " Missouri §onoral -3 Alier trust fu~d~ on Lme 45. See pages 9-10 for ~-'i' • Delivered N r I Wortors M , 1 L d MIiitary G Aovenue · Sci10ol a 1ona ernona ea Farnlr R-, · ,, .. , Re~ea1 a description of each trust fund, as well as ' Meals Guard Testing Rella trust fund codes to enter on Line 45.

PLEASE CHECK THE APPROPRIATE BOXES THAT APPLY TO YOURSELF OR YOUR SPOUSE AS OF DECEMBER 31, 2009. AGE 62 THROUGH 64 AGE §5 OR OLDER BLIND 10Q0b DISABLED t,IOt,1-0BLIGATED SPQUS!; 0 YOURSELF 0 YOURSELF D YOURSELF 0 YOURSELF D YOURSELF 0 SPOUSE D SPOUSE D SPOUSE 0 SPOUSE D SPOUSE

Yourself Spouse

1. Federal adjusted gross income from your 2009 federal return (See worksheet on page 6.) . 1Y 30,242 !00 1S I !00 2. Total additions (from Form MO-A, Part 1, Line 6) 2Y

.. ... · < O:i 00 2S ···•_.(HOO ................................. w 3. Total income -Add Lines 1 and 2 ............................................. 3Y 3Q;24~100 3S

'. . b!OO ::!!: 0 4. Total subtractions (from Form MO-A, Part 1, Line 14) .............................. 4Y , ))!00 4S . Q.!OO u z 5. Missouri adjusted gross income - Subtract Line 4 from Line 3 ....................... 5Y 30,M~dOO 5S Q!OO

6. Total Missouri adjusted gross income -Add columns 5Y and 5S. I 1····• . .................. '............... 6 ,.' ,· 30,242 :00 7. Income percentages - Divide columns 5Y and 5S by total on Line 6. (Must equal 100%) ... 7Y

' ..:-. •·J()Q: % 7S () %

8. Pension and Social Security/Social Security disability exemption (from Form MO-A, Part 3) ............... 8 () 00 9. Mark your filing status box below and enter the appropriate exemption amount on Line 9.

~A Single - $2,100 (See Box B before checking.) D E. Married filing separate (spouse D B. Claimed as a dependent on another person's federal · NOT filing)- $4,200

lax return - $0.00 D F. Head of household - $3,500 De. Married filing joint federal & combined Missouri - $4,200 0 G. Qualifying widow(er) with

9 '·· 2JOO 00 OD. Married filing separate - $2,100 dependent child - $3,500 10. Tax from federal return (Do not enter federal income tax withheld.)

• Federal Form 1040, Line 55 minus Lines 45, 63, 64a, 66, 67, and amounts from Forms 8801 and 8885 on Line 70 • Federal Form 1040A, Line 35 minus Line 40, 41 a, 43, and any alternative minimum tax included on Line 28

en • Federal Form 1040EZ, Line 11 minus Line 8 and 9a ........................... 10 : 00 z 11. Other tax from federal return -Attach copy of your federal return (pages 1 and 2). 11 ! 00 0 i= 12. Total tax from federal return - Add Lines 1 O and 11. ........................ 12 ,· (): ! 00 0 ~ 13. Federal tax deduction - Enter amount from Line 12 not to exceed $5,000 for individual filer; I Cl w $10,000 for combined filers ................................................................ 13 0 00 Cl Cl 14. Missouri standard deduction OR itemized deductions. Single or Married Filing Separate -$5,700; Head of z c:x: Household- $8,350; married Filing a Combined Return or Qualifying Widow(er) - $11,400; If you are age 65 or en older, blind, or claimed as a dependent, see your federal return or page 7. If you claimed an additional standard z 00 0 deduction or you are itemizing, see Form MO-A, Part 2, or Form MO-L .......................... 14 y 6,200 i= 15. Number of dependents from Federal Form 1040 OR 1040A, Line 6c ) ADonot D.

00 2: (DO NOT INCLUDE YOURSELF OR SPOUSE.) ............... · .. · .. · .. · · · BX $1,200 " · · 15 .. • .. • .·· 0 include w yourself >< 16. Number of dependents on Line 15 who are 65 years of age or older and do not J w 0

A or receive Medicai~ or state funding_(DO NOT INCLUDE YOURSELF OR SPOUSE.) X $1,000 = .. 16

·.··.····•· , .. • 00 spouse .

...

0 00 17. Long-term care insurance deduction .......................................................... 17 !< .. 18. Health care sharing ministry deduction ........................................................ 18 00 19. Total deductions-Add Lines 8, 9, 13, 14, 15, 16, 17, and 18 ...................................... 19 . .• 8,;300 00 20. Subtotal -Subtract Line 19 from Line 6 ................... , ................................... 20 21,942 00

21. Multiply Line 20 by appropriate percentages(%) on Lines 7Y and 7S .................. 21Y . 21,942!00 21S o!OO -·-·-~

22. Enterprise zone or rural empowerment zone income modification . ................... 22Y 100 22S i 00 23. Subtract Line 22 from Line 21. Enter here and on Line 24 ........................... 23Y · 21.942: 00 23S 0 '00

MO 860· 1094 (09-2009) For Privacy Notice, see the instructions.

s

24. Taxable income amount from Lines 23Y and 23S ................................ . 25. Tax. (See tax table on page 26 of the Instructions.) .............................. , . 26. Resident credit-Attach Form MO-CR and other states' Income tax return(s). OR ..... .

27. Missouri income percentage - Enter 100% unless you are completing Form MO-NRI. Attach Form MO-NRI and a copy of your federal return If less than 100%. Check the box

Yourself

21.942 l 00 24S 1,092.l 00 25S

146 00 26S

if you or your spouse is a professional entertainer or a member of a professional athletic team. J:JrYl!RSELF D sPousE .. . .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. 21v too.. % 21s

Spouse

0 .Q.Q 0 .QQ. 0 ].Q

100 % 28. Balance - Subtract Line 26 from Line 25; OR MO-CR value Is used

M It' I L. 25 b t L. 27 28Y 94·•,c.1 00 28'" 0 l 01" u 1p y 1ne y percen age on me . . ....................... , . . . . . r=-'- u ;..>!.'1<.4J=><><104--_____ -=--.t;-><,.><.lu

29. Othe0r taxes (Check box and attach federal form indicated.) · 1 !.'

Lump sum distribution (Form 4972) i D Recapture oflow income housing credit (Form 8611) .. . .. .. . .. . .. .. .. .. .. . .. 29Y ! 00 298 ! 00

30. Subtotal -Add Lines 28 and 29. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Y . ·. 946'! 00 30S . O i..Q.Q 31. Total Tax -Add Lines 30Y and 30S ............................................. ~.. .. . .. .. .. .. hl'" 9461 00 I

~ 32. MISSOURI tax withheld -Attach Form W-2(s) and/or Form 1099(s). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 422 i 00 @ 33. 2009 Missouri estimated tax payments (include overpayment from 2008 applied to 2009) . . . . . . . . . . . . . . . . . . . . . . . 33 i 00 5 34. Missouri tax payments for nonresident partners or S corporation shareholders - Attach Form M0-2NR. . . . . . . . 34 i UU ;;; 35. Missouri tax payments for nonresident entertainers -Allach Form M0-2ENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 i UU !z 36. Amount paid with Missouri extension of time to file (Form M0-60) . . . . . . . . . . . . .. . .. . .. .. .. . . . . . . . . . . . . . . 36 I 2 i UU ~ 37. Miscellaneous tax credits (from Form MO-TC, Line 13)-Attach Form MO-TC ........................ , . . . 37 " o · UU > ~· :rm-<( 38. Property tax credit - Attach Form MO-PTS. .. .. .. . . . . .. . . . . . . . . . . . . . . . . . .. .. . .. .. . . . . . . . . . . . . . .. . 38 i o i vv a. . - -~

39. Total payments and credits -Add Lines 32 through 38 .............................................. ·. 39 '•· 434 vu Skip Lines 4Q-42 if vou are not filing an amended return.

~ 40. Amountpaidonoriginalreturn .................................................................. ~ ~ 41. Overpayment as shown (or adjusted) on original return ............................................... ~ ~ INDICATE REASON(S) FOR AMENDING. M MI D D Y Y

~ lhliA. Federal audit .................................. Enter date of IRS report. Bl\: ~ l;l!;} B. Net operating loss carryback .......................... Enter year of loss. ~ WE) C. Investment tax credit carryback ....................... Enter year of credit. <C [fi D. Correction other than A, B, or C ... Enter date of federal amended return, if filed. ieyit"¥¥ m

w ::, Cl 1-z ::,

42. Amended Return - total payments and credits. Add Line 40 to Line 39 or subtract Line 41 from Line 39. . . . . . . 42 1 •. • • i 00

43. If Line 39, or if amended return, Line 42, is larger than Line 31, enter difference (amount of OVERPAYMENT) here. . . . .. . .. . .. .. .. . . . . . . . . . . . . . . . . . .. . . .. . .. . .. . . . . . .. . . . . . . .. . . . 1-4_3+·------'---o....,'r-'0'-0-1

44. Amount of Line 43 to be applied to your 201 O estimated tax ......................................... . 44 '00 0

45. Enler the ~mount of .!!!jl' Child,en·s '· .r Veterans I Elderly l Missouri eWorkers' /.d.\ Chlldtood ~ •.. M~sou,i ~eoeial ~ After Addi. Trust Addi. trust your donallon in the --~ ~ Home Naliooal Memorial v-c;;; Lead !/f M,Litary Revenue School Fund Code Fund Code lrusl fund boxes Delivered Guard TesUng ~~~.~ - Retreat (See Instr.) (See Instr.) to the right. See Meals _I __ 1_ instruclions for !rust fund codes. 45 I !oo !oo ioo po po ioo po !00 joo !oo joo .__......___..._..__ _ ____._......._ __ ...... ...._ _ _.___._ ___ ..__..__ __ ...._..___..._....__ __ ...._,,____,._ ................ _ __,____,__.,..,_--I

~ 46. Overpayment to be refunded to you. Subtract Lines 44 and 45 from Line 43 and enter here. Sign below and <C mail return to: Department of Revenue, PO BOX 3222, JEFFERSON CITY, MO 65105-3222 a: REFUND 46 I·· O 00 0 t----t,-.-,,,--c...-----------,----,...c....,-1

~ 47. If Line 31 is larger than Line 39 or Line 42, enter the difference (amount of UNDERPAYMENT) here ........... ,_4_7-+-\ _____ 5_l2_· ._0_0--1 ~ 48. Underpayment of estimated tax penalty -Attach Form M0-2210. Enter penalty amount here. . . . . . . . . . . . . . . 1-4'-8-+-------;-0"--Q-'-l ~ 49. Total amount due -Add Lines 47 and 48 and enter here. Sign below and mail return and payment to:

Department of Revenue, PO BOX 3370, JEFFERSON CITY, MO 65105-3370. Please write your social security number(s) and daytime phone number on your check or money order (U.S. funds only).

Make payable to Missouri Department of Revenue ............................. AMOUNT YOU OWE ._4_9 .... '___;_· ____ 5 _12~0_0___,

ti you pay by check, you authorize the Department of Revenue to process the check electronically. Any check returned unpaid m,1y be presented again electronically.

Under penalties of perjury, I declare Iha! I have examined this return, including accompanying schedules and stalemenls, and to lhe best ol my knowledge and belief ii is true, correcl, and complete. Declaralion ol preparer (olher than taxpayer) is based on all information ol which he/she has any knowledge. As provided in Chapter 143. RSMo, a penalty ol up to $500 shall be imposed on any individual who files a frivolous return. I also declare under penalties of perjury that I employ no illegal or unauthorized aliens as defined under federal law and that I am not eligible lor any tax exemption, credit or abatement ii I employ such aliens.

WJ----------------------------....--------------.----------------l ~ I authorize the Director of Revenue or delegate to discuss ...!!!Y return and attachments I E-MAIL ADDRESS PREPARER'S TELEPHONE

~ with the preparer or any member of the preparer's firm. LJ YES O NO

~ Sl(iN~TliRE DATE

en PREPARER'S SIGNAlURE I FEIN, SSN. OR PTIN

Sf/01/iiE'S SIGNATURE (H filing combined, BOTH must sign) DAYTIME TELEPHONE PREPARER'$ ADDRESS AND ZIP CODE I DATE

MO 860-1094 (09-2009) This form is available upon request in alternative accessible format(s).

""''"'"'\\i,. ,/;,::,:::.~::;:!_\ MISSOURI DEPARTMENT OF REVENUE

{(~ · {.J INCREASE TO STANDARD DEDUCTION '\;~w FOR CERTAIN FILERS

2009 FORM

MO-L ".'~u ml:'st complete Form MO-L if you are increasing your standard deduction by a net disaster loss, state:or local real estate taxes, or new motor vehicle taxes. Be sure to attach yom federal return and

I' , federal Schedule L when you file.

'' ' YOUR NAME YOUR SOCIAL SECURITY NO.

DOUGLAS M ELLIS 419 SPOUSE'S NAME SPOUSE'S SOCIAL SECURITY NO.

1. Enter the standard deduction for your filing status: • Single or Married Filing Separately - $5,700 • Married Filing Combined or Qualifying Widow(er) - $11,400 • Head of ~ousehold - $8,350 • Claimed as a dependent - enter amount from Line 4 of federal Schedule L. 1.

l 2. If you are over 65 or blind, enter the amount reported on Line 5 of federal ! 00 Schedule L ...................................................... ,_2_._,_ ________ --.-__.

' 3. Enter the amount of any net disaster loss included in your standard deduction i

00 and reported on Line 6 of federal Schedule L. . ......................... t--3_. -1--------------,,-----i

! 4. Enter the amount of state and local real estate taxes included in your standard sool 00 deduction and reported on Line 9 of federal Schedule L. .................. t--4-·--+-----------+---------1

5. Enter the amount of any new motor vehicle taxes included in your standard l 00 deduction and reported on Line 20 of federal Schedule L. . . . . . . . . . . . . . . . . . 5.

6. Add the amounts shown on Lines 1 through 5 and report the total here and on Form M0-1040 Line 14. . ......................................... .

-~~~~~~ (t!~t\\ MISSOURI DEPARTMENT OF REVENUE '" ~ ;_:]! "'i;~.tJti.ff HOME ENERGY AUDIT EXPENSE NAME OF TAXPAYER

DOUGLAS

2009 FORM

MO-HEA M ELLIS

Beginning January 1, 2009, any taxpayer who paid an individual certified by the Department of Natural Resources to complete a home energy audit may deduct 100% of the costs incurred tor the audit and the implementation of any energy efficiency recommendations made by the auditor. The maximum yearly subtraction may not exceed $1,000, for a single taxpayer or a married couple filing a combined return. For all years in which you incur expenses, the maximum total subtraction you may claim is $2,000. To qualify for the deduction, you must have incurred expenses in the year you are filing a claim, and the expenses incurred must not have been excluded from your federal adjusted gross income or reimbursed through any other state or federal program.

INST~l!CTIONS- IN'TH~ SPACES PROVIDED BELOW: ·

• Report the name of the auditor who conducted the audit • Summarize each of the auditors recommendations • Enter the total amount paid to implement the energy efficiency

recommendations on Line B • Attach applicable receipts

NAME OF AUDITOR

1.

2.

3.

4.

5.

• Report the auditor's certification number • Enter the amount paid for the audit on Line A • Enter the total amount paid for the audit and any implemented

recommendations on Line C • Attach completed MO-HEA and receipts to Form M0-1040

AUDITOR CERTIFICATION NUMBER

A. Amount paid for audit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-A_. +-------------;!_0_0--i B. Amount paid to implement recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ! 00 C. Total Paid - Add Lines A and Band enter here. Enter Line C or $1,000, whichever is less, on Line 13of Form <i·•···t ..

MO-A. If you are filing a combined return, you may split the amount reported on Line 13 between both taxpayers. . . . JOQ

:·.. MISSOURI DEPARTMENT OF REVENUE (, ,J)l CREDIT FOR INCOME TAXES PAID TO "'.lf.)/ OTHER STATES OR POLITICAL SUBDIVISIONS

Complete this form for you and your spouse, If you and/or your spouse have income from another state or polltlcal subdivision. If you had multiple credits, complete a separate form for each state or political subdivision. YOUR NAME

DOUGLAS ELLIS

1. Claimant's total adjusted gross income (Form M0-1040, Line SY and/or Line 5S)

2. Claimant's Missouri income tax

YOUR SOCIAL SECURITY NO.

4 9

2009 Attachment Sequence No. 1040-03

FORM

MO-CR • Attach a copy of all Income tax returns for each state or

polltlcal subdivision.

• Attach Form MO-CR to Form M0-1040.

YOUR SPOUSE'S NAME

i Form M0-.1040 Line 25Y and/or Line 25S ........................................ . 1,09:2100 2

USE TWO LEITER ABBREVIATION FOR STATE OR NAME OF POLITICAL SUBDIVISION. See table on back.

3. Wages and commissions ..................................................... .

KS

4,885 ! 00

STATE OF:

3

O 100

i 00 :00 4 ! 00

4,$85 l 00 0100 4. Other (describe nature) . . .. . . . . . . . . . .. .. . . .. . 1--,-------+-=--=+-..:.....-i--,------+-=-=-l

5 67 100 l 00

5. Total-Add Lines 3 and 4 ..................................................... ~"""""'-'-"----'==-:-....;..::::-1-::......i"'-'-~--~--=-:--'=-!

6 4.8f8 00 0 I 00

6. Less: relaled adjustments (from Federal Form 1040A, Line 20, OR Federal Form 1040, Line 36) .. f,,,.,,,~,.,,...,---~:+:~r-+-,.,..,...,--,----~H-:~ 7. Net amounts - Subtract Line 6 from Line 5. . . . . . . . . . . . . . .. .. . . . .. . . . .. . .. .. . .. . .. . lc'-"'-'--'-~~~-'"--''-"--'--,:-i'-t-'-f,.,,,.,.---.-,..---__.._-,:-i-1 7

16 % 8 () % 175 00 OiOO

8. Percentage of your income taxed - Divide Line 7 by Line 1. .. .. . . . .. . . . . .. .. . . . . .. .. . p;cc~c...-~~--'-'C-,-~-1-::......i=-~~~--~~

9 9. Maximum credit - Mulliply Line 2 by percentage on Line 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-~~---=--==-t...::....::+-.c......-iP-~------"-+....::....::...

10. Income tax you paid to another state or political subdivision. This Is not tax withheld. 146 00 10 00 The income tax is reduced by all credits, except withholding and estimated tax. . . . . . . . . . . . . . . 1--------+...::....::+-~------,---+....::....::...

11. Credit - Enter the smaller amount of Line 9 or Line 1 O here and on Form M0-1040, Line 26Y or Line 26S. (If you have multiple credits, add the amounts

146 00 on Line 11 from each Form MO-CR before enterin on Form M0· 1040 ................. . 11 For Privacy Notice see the Instructions

.#;,?:'!:._ MISSOURI DEPARTMENT OF REVENUE fC: ' CREDIT FOR INCOME TAXES PAID TO "~~~~ OTHER STATES OR POLITICAL SUBDIVISIONS

Complete this form for you and your spouse, if you and/or your spouse have income from another state or political subdivision. If you had multiple credits, complete a separate form for each state or political subdivision.


FORM

MO-CR • Attach a copy of all income tax returns for each state or

political subdivision.


O 00

YOUR NAME YOUR SOCIAL SECURITY NO. YOUR SPOUSE'S NAME SPOUSE'S SOCIAL SECURITY NO.

DOUGLAS ELLIS



4 9

Form M0-1040 Line 25Y and/or Line 25S ....................................... . USE TWO LEITER ABBREVIATION FOR STATE OR NAME OF POLITICAL SUBDIVISION. See table on back.

3. Wages and commissions ..................................................... . 4. Other (describe nature) ..................... . 5. Total - Add Lines 3 and 4. . .................................................. . 6. Less: related adjustments (from Federal Form 1040A, Line 20, OR Federal Form 1040, Line 36) .. 7. Net amounts - Subtract Line 6 from Line 5 ....................................... . 8. Percentage of your income taxed - Divide Line 7 by Line 1. . ........................ . 9. Maximum credit - Multiply Line 2 by percentage on Line 8 ........................... .

10. Income tax you paid to another state or political subdivision. This is not tax withheld. The income tax is reduced by all credits, except withholding and estimated tax. . ............ .

11. Credit - Enter the smaller amount of Line 9 or Line 1 O here and on Form M0-1040, Line 26Y or Line 26S. (If you have mulliple credits, add the amounts on Line 11 from each Form MO-CR before enterin on Form M0-1040 ................. .

STATE OF:

For Privacy Notice see the instructions

1,092 ! 00

! 00 iOO

0100 i 00

0:00 ·o % ():00

00

o 00

0 00 STATE OF:

3 00 4 00 5 0 00 6 00 7 0 00 8 0 % 9 0 00

10 00

11

Form. W-2 Wage and Tax Statement c Employers name, address, and ZIP coda

LiTTLE CAESAR ENTERPRISES INC. 2211 WOODWARD AVENUE DETROIT MI 48201-34 67

e Employee's name, address, and ZIP code

DOUGLAS M ELLIS 7904 E. 127TH TERRACE GRANDVIEW MO 64030-2103

20w 1

15 Stale KS

Employers slate I.D. no. 036-381720166F

16 Slate wages, lips, elc. 4885.27

7 Social security lips

8 Allocated lips

9 Advance EiC paymanl

10 Dependant care benefits

ReUrem11n1 Piao

b Employer ldenlillcalion number (EIN) 38-1720166

ial securlly no. -9419

Wagei olhar comp. 4885.27

3 Social security wages 4885.27

5 Medicare wages and lips 4885,27

11 Nonquallflad plans

14 Olher

2 Federal Income lax wilhheld 780.00

4 Social security lax wllhheld

302.89 B Medicare lax wl/hhald

70. 84

17 Slate income lax 68.00

1_a Local wages, lips, etc. 19 Local income tax 20 Locality name :;

··- ---······--·- ····-·······- ···-···-····· .. ., ••. ------(C 0

Copy2=T~o·s~e~F=u·e-d'W""it~h~E·m~p~l~o~y~e~e~'s'S~tLa~te-,~C"""lty~,~o-r~L-o-ca-l'l'n_c_o_m_e--..T~a~x·R~e~t~u=rn::-'--~~~~~~~~~--'-~~o~M7.B~N~~-1=s~,s~-ooo==e:-~~~-'-~~~~~~,D'"e=p"l.~07t~th~_.~T~re~a~s=u=ry~--1~A~s~~

' ------------··------------------------- ... ---------------------------------------------------------------H-----------------------------------------------------0.

:opy 2 To Be Filed Wllh Employee's Slate, City, or Local Income ·ax Return. :arm:

N-2 Wage and Tax Statement 2009

c:pt. of .the Treasury--lnternal Revenue Service

b la.I ,ecurlly number

-9419 ldi:nllflcallon number IEINJ

36-.::951565 c E"1np101er', name. addrtn, and ZIP cude

MCDONALD'S CORP AS AGENT MCDONALDS REST. OF MISSOURI INC 2111 MCDONALD'S DRIVE OAK BROOK IL 60523

d Control number

0098591 ·"·•

e Emploffl"\'"llnl n'a'tti~· 111d lnlllal La,t name

DOUG M ELLIS 7904 E 127TH TER GRANDVIEW MO 64030-2103

I Employee·, addru1 a,id ZIP codt

'M(t' 12717f7 4"'' ID NO 16 51.ile w.ige.s. Ups. tic.

17,684.27 ___ L _____________________ --------------------

I

,DMEI No .. l54S·000B

I• w .. ,, olhcr c:ompi:nnliun 2 fi:d1n1I lncomt I.ax wllhheld

17,6~4.27 1,5::li,::,5 J Socia.I seeurU)' wagtl 4 Socia! ucurilr tax wl!hheld

17,684.27 1,096.42. ,,_

5 Mediurt wa9t1 an; 1: 684

• 27

6 Mtd/cart l:111' w/lhhthf

256.42 7 Soei11I ncurll)' lips

0.00 8 Allonl111d .tips

0.00

9 Advance EiC payment 10 DepHd,nt cue bu"fils

0.00 0.00 Sull. II Nonqualille.d pJan1 ; 12a

I 0.00 • . IJ Slalulory Rtlin!mtnl Thlrd·party ~ 12b tmalo)'ce er sick pay

I D D • . 14 OIiier ~ 12c

I • . ! 12d

I • . 17 Slalt i,icome tax IB LQcal wa9ts, lip,. etc. 19 Local l,icomt! tu: 20 Localil)' N<1me

422.00 ---------------- -------------- --------------

... ______ .,. __

f2Iii4-• ·o; . ~,..,

(R~v. 9/09)

DO NOT STAPLE

2009 KANSAS ~ND~V~DUAl ~NCOMfE 1 AX

amol/or f OOD SALES TAX REFUND

114 50 9

Y6ur First Name I lnllial !Last Name

''l I r1 '' '' 11 1111 1· ·· I ·1 · 11

' I Enter the' flrst four letters of your last name.

l,1 11n11,! 11uHIJ!l11111 1 111 111i; Jiil1111 1d 1111. I Use ALL CAPITAL letters.

L

I

,t-,'0:-!H:f~i,·:0 ;;.;'·i:H,·~ECR'lfli .;i rrG(l J. .3 OS7295i

JYourSoclal ..... O' · Security numbe _ _ '( 1../ I 9

~ I

.. '

nnu,;L~s n f.1LJS 7'904 E J.27TH TtR Gft4NliViE!:J RD fi!JOJ0-2103

Clly, Town, or Post Office

If your name or address has changed since last year, mark an "X" in this box

I Stale I Zip Code County Abbrevlalio,

If taxpayer (or spouse If filing joint) died during this tax year, mark an "X" in this box

Enter the first four letters of your spouse's last name. Use ALL CAPITAL letters.

Spouse's Social Security numb'er

Daytime telephone 'fr / r. number co

~-- · ----- ··· ........... ===~·---·--·==~~-·"'"-"""""'"'"·"===m=,on--~~==.,v;,,.-,,.,._..,,,,.~~ · ~ .4· --,,-

~ ,, Reason for amending your 2009 original Kansas return: I ~ Mark this box if you are filing this as ~ an AMENDED 2009 Kansas return. Amended affects Amended Federal Adjustment by fi NOTE: This form cannot be uced for tax years prior lo 2009. KN!~S only tax return the IRS ~

\,._ ___ =========== ---- - ---- - =--=--==----~------=:-------=~-====- -----="''

E)(emptions Filing Status (Mark ONE)

X Single

Married filing joint

Residency Status (IVlark ONE)

Resident Number of exemptions claimed on your 2009 federal return . . . . . . I

(Even if only one had income) X Nonresident or Part-year resident from_/_/_ to_/_/_ (Complete Schedule S, Part B)

If filing status is head of 0 household, add one exemption ...... . Married filing separate

Head of household (Do not mark this box if you are filing a joint return)

Total Kansas exemptions . . . . . . . ./

If amount is negative, shade the minus(-) in box. Example: ....

1. Federal adjusted gross income ........................................... .

2. Modifications (From Schedule S, line A 19). Enclose Schedule S ................ . 0

3. Kansas adjusted gross income (Line 2 added to or subtracted from line 1; see instructions) .......................................................... .

4. Standard deduction OR itemized deductions (See instructions) .......................... . 3 0 D 0

5. Exemption allowance ($2,250 x number of exemptions claimed) ................................. . 2 ;:1 5 0

6. Total deductions (Add lines 4 and 5) ............................................... . §' i fl 0 7. Taxable income (Subtract line 6 from line 3; if less than zero, enter 0) ................. . I 1 t.f '7 J

I

8. Tax (From Tax Tables or Tax Computation Schedules) ................................ . (,? 'iT 0 9. Nonresident allocation percentage (from Schedule S, line 823). If 100%, enter 100.0000.

Enclose your completed Schedule S with this form ..................................... . 'I I 5' 0 r-

10. Nonresident tax (Multiply line 8 by line 9) ........................................... . I t/ 6 11. Kansas tax on lump sum distributions (Residents only - see instructions) .................. . 0

12. TOTAL INCOME TAX (Residents: add lines 8 & 11; Nonresidents: enter amount from line 10) .. . I L( 6

r

114209

TAX: Enter the income tax amount from line 12 Nie I()()

13. Credit for taxes paid to other states (See instructions. Enclose return(s) from other statas.) ..... .

14. Credit for child & dependent care expenses (See instructions) .............................. .

15. other credits (Enclose all. appropriate credit schedules) ..... , .......................... .

16. Total tax credits (Add lines 13, 14 and 15) ............................................ ·.

17. Income tax balance after credits (Subtract line 16 from line 12; cannot be less than zero) .... .

18. Use tax due (See instructions) .................................................................. .

19. Total Tax Balance (Add lines 17 and 18) ........................................... .

20. Kansas income tax withheld from W-2, 1099, or K-19 (Enclose K-19; see instructions) ...... .

21. Estimated tax paid ........................................ .

22. Amount paid with Kansas extension .............................................. .

23. Earned income credit (See instructions) ......................................................... .

24. Refundable portion of tax credits (Enclose all appropriate credit schedules) ................ .

25. FOOD SALES TAX REFUND (You must meet ALL the qualifications; see instructions) .................... .

26. Payments remitted with original return ......................... _ .................. .

27. Overpayment from original return (This figure is a subtracti_on; see instructions) ............ .

28. Total refundable credits (Add lines 20 through 26 and subtract line 27) .............. .

29. UNDER_~A YMENT (If line 19 is greater than line 28, enter the difference here) ........... .

30. Interest (See instructions) ............................................................. .

31. Penalty (See.instructions) ................................................ '. ............ . . . . . Check here if you were engaged in

32. Estimated Tax Penalty (See 1nstruct1ons). . . . . . . . . . . . commercial farming or fishing in 2009.

33. AMOUNT YOU OWE (Add lines 29 through 32. Include amounts from lines 36 through 39, if applicable.) See instructions for payment options ................................... .

34. OVERPAYMENT (If line 19 is less than line 28, enter the difference here) ................ .

35. CREDIT FORWARD (Enter the amount of line 34 you wish to be applied to your 2010 estimated tax) ... .

36. CHICKADEE CHECKOFF (Kansas Nongame Wildlife Improvement Program) ............. .

37. SENfOR CITIZENS MEALS ON WHEELS CONTRIBUTION PROGRAM ................ .

38. BREAST CANCER RESEARCH FUND ........................................... .

39. MILITARY EMERGENCY RELIEF FUND .......................................... .

40. REFUND (Subtract lines 35 through 39 from line 34. SIGN your return below.) .......... .

I authorize the Director of Taxation or the Director's designee to discuss my return and enclosures with my preparer.

Ef\lCLOSE any necessary diocuments with this form. DO NOT STAPLE.

C'

0

0

L

0

r

SCCHfEfDULE S 2009 114309

(Rev. 9/09) KANSAS SU~flllEMENlf Al SCHJEIDUlE

~Y-o_u_r -Fi-rs-t -Na_m_e ________ ,._ln-iti-al..,__La_s_t N_a_m_e __ --~----i !Jol!c.,",::.p5 1:lt e (....C.( 5 __J

Spouse's First Name Initial Last Name

Enler the first four letters of your last name. Use ALL CAPITAL letters.

Your Social -Security number . ,J

Enter the first four letters of your spouse's last name. Use ALL. CAPITAL letters.

Spouse's Social Security number

L

Cf I 9

PART A~ MODIFICATIONS TO FEDERAL ADJUSTEO GROSS INCOME {See instructions)

ADDITIONS TO FEDERAL ADJUSTED GROSS INCOME:

A 1. State and municipal bond interest not specifically exempt from Kansas Income tax (Reduced by related expenses) ............................................. .

A2. Contributions to all KPERS (Kansas Public Employee's Retirement Systems) (See Instructions) ........ .

A3. Federal net operating loss carry forward .................................................... .

A4. Contributions to a Regional Foundation (See instructions) ...................................... .

AS. Other additions to Federal adjusted gross income (See instructions and enclose list) ................. .

A6. Total additions to Federal adjusted gross income (Add lines A 1 through AS) ........................ .

SUBTRACTIONS FROM FEDERAL ADJUSTED GROSS INCOME:

A7. Social Security benefits (See instructions) .................................................. .

AB. KPERS Jump sum distributions exempt from Kansas income tax (See instructions) ................. .

A9. Interest on U.S. Government obligations (Reduced by related expenses) ......................... .

A10. State or local income tax refund (If included on line 1 of Form K-40) ............................. .

A 11. Kansas net operatif]g loss carry forward ................................................... .

A 12. Retirement benefits specifically exempt from Kansas income tax (Do not include Social Security benefits or KPERS lump sum distributions) .................................................•......

A 13. Military Compensation of a Nonresident Servicemember (Nonresidents only; see instructions) ........ .

A 14. Qualified Long-Term Care (L TC) insurance premiums (See instructions) .......................... .

A 15. Contributions to Learning Quest or other states' qualified tuition programs (See instructions) .......... .

A16. Armed Forces Recruitment, Sign-up, or Retention Bonus ...................................... .

A 17. Other subtractions from Federal adjusted gross income (See instructions and enclose list) ............ .

A 18. Total subtractions from Federal adjusted gross income (Add lines A? through A 17) .................. .

NET MODIFICATIONS:

If amount is negative, shade minus (-) in box. Example: =

A 19. Net modifications to Federal adjusted gross income (subtract line A 18 from line A6). Enter on line 2, Form K-40. If negative, shade minus(·) in box .............................. .

(;,

0

0

0

0

0

0

0

0

0

0

0

0

(J

0

CJ

0

r

114409 L PART Ba NONRESIDENT AllOCATiON (See instructions)

If amount is negative, shade the minus(-) In box. Example:

INCOME:

81. Wages, salaries, tips, etc ................. .

82. Interest and dividend iricome ............. .

83. Refuni:ls of state and local Income taxes ..... .

84. Alimony received ....................... .

85. Business income or loss ............. .

86. Farm income or loss ................ .

87. Capital gain or loss ................. .

88. Other gains or losses ............... .

89. Pensions, IRA distributions, and annuities

810. Rental real estate, royalties, partnerships, S corporations, estates, trusts, etc ..... .

811. Unemployment compensation, taxable Social Security benefits, & other income ..

Total From Federal Return:

0

0

0

0

812. Total income from Kansas sources (Add lines 81 through 811) ......................... .

ADJUSTMENTS AND MODIFICATIONS TO KANSAS SOURCE INCOME:

Total From Federal Return:

813. IRA Retirement Deductions ................ . ~

814. Penalty on early withdrawal of savings ....... . (. '7

815. Alimony paid ............................ . ei

816. Moving expenses ........................ . 0

817. Other federal adjustments ................. . 0

818. Total federal adjustments to Kansas source income (Add lines 813 through 817) ........... .

819. Kansas source income after federal adjustments (Subtract line B18 from line B12) .......... .

B20. Net modifications applicable to Kansas source income (See instructions) ................. .

B21. Modified Kansas source income (Line 819 plus or minus line B20) ...................... .

822. Kansas adjusted gross income (From line 3, Form K-40) ................... : .......... .

823. Nonresident allocation percentage (Divide line 821 by line B22 and round to the fourth decimal place; not to exceed 100.0000). Enter result here and on line 9 of Form K-40 .............. .

Amount From Kansas Sources:

'I 'iJ "!, 5 0

0

C)

0

0

0

0

0

0

t.f '6' i 5

Amount From Kansas Sources:

0

0

0

(I

0

~11, S 6

)'21"J __ r.f

2 I 5 cJ

r

FORM DLN

I

. CON~ftiilN.tlAL . . :"~ ~}!f'JMES BE AFf1~6:g.Js:rtU:COVER DOQ~iylENT TO.THIS RETURf{

· ·. · }\/AME: CONTROL

I 1· 1· ~J I I I

· 0 (RVCP). Revie.Jrof i'~tonnatio11 Co~pleted D (GERT) Statute.E')5pited· :.C Certificatlon •·· · · ... 0 (UNU$) l:JntJsat?Je/l(lsufficieht Audft . 0 .(C,OLL) CollectEJ!'.1/Pa~El . .

OOR,4801 (03-2013)·

'futemal Revenue Service _ United States Department of the Treasury

This Product Contains Sensitive Taxpayer Data

Account Transcript Request Date: 05-12-2014

05-12-2014

100196445704

FORM NUMBER: 1040

TAX PERIOD: Dec. 31, 2009

TAXPAYER IDENTIFICATION NUMBER:

DOUGLAS MELLIS

7904 E 127TH TER

GRANDVIEW, MO 64030-2103-047

Response Date:

Tracking Number:

9419

--- ANY MINUS SIGN SHOWN BELOW SIGNIFIES A CREDIT AMOUNT ---

ACCOUNT BALANCE:

ACCRUED INTEREST:

ACCRUED PENALTY:

ACCOUNT BALANCE PLUS ACCRUALS (this is not a payoff amount):

0.00

0.00

0.00

0.00

** INFORMATION FROM THE RETURN OR AS ADJUSTED**

EXEMPTIONS:

FILING STATUS:

ADJUSTED GROSS INCOME:

TAXABLE INCOME:

TAX PER RETURN:

SE TAXABLE INCOME TAXPAYER:

SE TAXABLE INCOME SPOUSE:

TOTAL SELF EMPLOYMENT TAX:

RETURN NOT PRESENT FOR THIS ACCOUNT

00

Single

TRANSACTIONS

CODE EXPLANATION OF TRANSACTION

n/a No tax return filed

460

140

971

Extension of time to file ext. Date 10-15-2010

Inquiry for non-filing of tax return

Notice issued CP 0059

CYCLE DATE

04-15-2010

04-13-2011

05-02-2011

AS OF: Jun. 02, 2014

AS OF: Jun. 02, 2014

Exhibit B

AMOUNT

$0.00

$0.00

$0.00

MISSOURI DE~ARTMENT OF REVENUE TAXATION DIVISION FEOERALINE6>Jll\/lATION

' ,CLOSING ·RBPORT

FORM

4797

DLN .. ·

11 I I I I I I r r .11 I I I I - - - ._- ,-,_·--:,:-,,..:._!';.~-:. ---:., :

(REV. 07-2010)

__ TAXTYPE

CONFIDl!NTIAL t~~ISJ)OCUMf:NTMU:~~T~lL TIME$ aEAF_EIX~~ ASTHE COVERDOCUMENTTO THIS RETURN: ·- , •. \ I f:.· I Elvl ·

·~lh:qri~ed aisc1qsureioo~l1r unauthorized insp~Ml@'ot return intormation ma~/ resu1t in crimina1 or .civil action as authorized by-the malE1evem,eCo~e,.;§.i¥tJ,.<;>!1]213,7213AancU9rz;~~l, .·~ .. _ · - ·· - · - - ·

-.~-y __ - .. - -

.:. - -\' ~~\~·-X - MIJS NUMBgR .. ·- NAME CONTROL FIRST INITIAL

-- L,--1,_____I ···~L . •_._____I -- . ..L_L · ..___I ·_·· 1~1 I I I I · I I I I D

ff.(tA:IJ!ijGe~~$ffBE¥IE~;;-eHeckA]3f>(:f0RR1ATf;';"CC'OSiNG-CODE- -.•·_ .~o:c(~W'LNoJ\c:tion·Neoessary -

41 (~J~t)Outof Statute · b .<NE}lt)}fo Business in Missouri

·. .o '(N'-OP) Cannot Locate Ja,cpayel - _"'_-. ~ ~·-"' "_, -~~- . -.- -. - . - .

G (RVCP) Revi~woflnfc:irmation c1mpleted 0 (CERT) Statuta f;.xpin:id - Certification D {UNUS) Unus.c:1ble/lrisufficient Audit -D. (Cbl.L) Collecte~/Raye

.- 0 (NSB[)Billing o· (NSEV).Even _ ·-- o'(r-.is~J~)'Ret,.md o (FAPR).Active Billing

,~,t,,,,.,,___.,,.....__,.. ___ -,-.....,.....,.,.,"""";--.-...--.--------,---..,..-,,------------------..;..------.. BUREAU - CLOSED ON FAP.S-c. STAMP DAT!:

!ffiV (Ns1::cj Error~o_dtrEiJt1tih' -. ·• -tQ . (NSAS) Asse,ssrnelit i~;··

D0R'4797 (07-2010)

Wage and Income Transcript Page I or 15

fa Internal Revenue Service · United States Department of the Treasury

I This Product Contains Sensitive 1'axpayer Data

Wage and Income Transcript Request Date: 05-13-2014

05-13-2014

100196621331

SSN Provided: ~-9419

Tax Period Requested: December, 2009

Form W-2 Wage and Tax Statement

Employer: Employer Identification Number (EIN): 362951565

MCDONALDS REST. OF MISSOURI INC

2111 MCDONALDS DRIVE

OAK BROOK, IL 60523-2199

Employee: Employee's Social Security Number:~-9419

DOUG MELLIS

7904 E 127TH TER

GRANDVIEW, MO 64030-2103

Submission Type:

Wages, Tips and Other Compensation:

Federal Income Tax Withheld:

Social Security Wages:

Social Security Tax Withheld:

Medicare Wages and Tips:

Medicare Tax Withheld:

Social Security Tips:

Allocated Tips:

Advanced EIC Payment:

Dependent Care Benefits:

Deferred Compensation:

Code "Q" Nontaxable Combat Pay:

Code "W" Employer Contributions to a Health Savings Account:

Response Date:

Tracking Number:

Original document

$17,684.00

$1,551.00

$17,684.00

$1,096.00

$17,684.00

Code "Y" Deferrals under a section 409A nonqualified Deferred Compensation plan:

$256.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

Code "Z" Income under section 409A on a nonqualified Deferred Compensation plan:

Code "R" Employer's Contribution to MSA:

Code "S" Employer's Contribution to Simple Account:

Code "T" Expenses Incurred for Qualified Adoptions:

Code "V" Income from exercise of non-statutory stock options:

Code "AA" Designated Roth Contributions under a Section 40l(k) Plan:

Code "BB" Designated Roth Contributions under a Section 403(b) Plan:

Third Party Sick Pay Indicator:

Retirement Plan Indicator:

Statutory Employee:

Form W-2 Wage and Tax Statement

https://la 1. wwvv4.irs.gov/semail/servlet/FileDownload

Unanswered

Unanswered

Not Statutory Employee

Exhibit C

05/13/2014

Wage and Income Transcript

Employer: Employer Identification Nwnber (EIN): 381720166

LITTLE CAESAR ENTERPRISES INC

2211 WOODWARD AVENUE

DETROIT, MI 48201-3467

Employee: Employee's Social Security Nwnber: ~9419

DOUGLAS MELLIS

7904 E, 127TH TERRAC


Submission Type:

Wages, Tips and Other Compensation:


Social Security Wages:

Social Security Tax Withheld:

Medicare Wages and Tips:

Medicare Tax Withheld:

Social Security Tips:

Allocated Tips:

Advanced EIC Payment:

Dependent Care Benefits:

Deferred Compensation:

Code "Q" Nontaxable Combat Pay:

Code "W" Employer Contributions to a Health Savings Account:

Code "Y" Deferrals under a section 409A nonqualified Deferred Compensation plan:

Code "Z" Income under section 409A on a nonqualified Deferred Compensation plan:

Code "R" Employer's Contribution to MSA:

Code "S" Employer's Contribution to Simple Account:

Code "T" Expenses Incurred for Qualified Adoptions:

Code "V" Income from exercise of non-statutory stock options:

Code "AA" Designated Roth Contributions under a Section 40l(k) Plan:

Code "BB" Designated Roth Contributions under a Section 403(b) Plan:

Third Party Sick Pay Indicator:

Retirement Plan Indicator:

Statutory Employee:

Schedule K-11065

Partnership: Partnership's Employer Identification Number: 351811116

CALUMET SPECIALTY PROD PARTNERS LP

2780 WATERFRONT PARKWAY EAST DRIVE

INDIANAPOLIS, IN 46214-0000

Partner: Partner's Identifying Nwnber:

DOUG ELLIS

7904 E 127TH TER


Submission Type:

Dividends:

Interest:

Royalties:

Ordinary Income K-1:

9419

https://lal .www4.irs.gov/semail/servlet/FileDownload

Page 2 of 15

Original document

$4,885.00

$780.00

$4,885.00

$302.00

$4,885.00

$70.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

Unanswered

Unanswered

Not Statutory Employee

Original document

0.00

0.00

0.00

-$6.00

05/13/2014


Real Estate:

Other Rental:

Guaranteed Payments:

Section 179 Expens~s:

Short Term Capital Gain:

Long Term Capital Gain:

Page 3 of 15

0.00

0. 00

0.00

0. 00

0.00

0.00

Form 1099-B Proceeds From Broker and Barter Exchange Transactions

Payer: Payer's Federal Identification Nwnber (FIN): 860381976

SCOTTRADE INC

12800 CORPORATE HILL 5TH FL

ST LOUIS, MO 63131-0000

Recipient: Recipient's Identification Number: ~9419

DOUG ELLIS

7904 E 127TH TER


Submission Type:

Account Number:

Date of Sale or Exchange:

CUSIP Nwnber:

Gross Proceeds:

Bartering:


Stocks.and Bonds:

Aggregate Profit or (Loss):

Realized Profit or (Loss):

Unrea.li.zed Profit or (Loss) 12/31 Prior Year:

Unrealized Profit or (Loss) 12/31 Current Year:

Description:

Second Notice Indicator:

Number of Shares Exchanged:

Class/Classes of Stock Exchanged:

Recipient Indicator:

Original document

777 28667225 24G

09-02-2009

156431108

Gross proceeds minus commissions and option premiums

0.00

0.00

$204.00

0.00

0.00

0. 00

0.00

23 CENTURY ALUM CO

No Second Notice

0000000000000

Loss can be taken on tax return


Payer: Payer's Federal Identification Nwnber (FIN): 860381976

SCOTTRADE INC


ST LOUIS, MO 63131-0000

Recipient: Recipient's Identification

DOUG ELLIS

7904 E 127TH TER


Submission Type:

Account Number:


-9419

https://lal. www4.irs.gov/semail/servlet/FileDownload

Original document

777 28667225 24G

09-02-2009

05/13/2014


CUSIP Number:

Gross Proceeds:

Bartering:


Stocks and Bonds:



Unrealized Profit or (Loss) 12/31 Prior Year:


Description:





Page 4 of 15

345370860


0.00

0.00

$352.00

0.00

0.00

0.00

0.00

50 FORD M'rR CO

No Second Notice

0000000000000



Payer: Payer's Federal Identification Number (FIN): 860381976

SCOTTRADE INC


ST LOUIS, MO 63131-0000

Recipient: Recipient's Identification Number: 11111111-9419

DOUG ELLIS

7904 E 127TH TER


Submission Type:

Account Number:

Date of Saie or Exchange:

CUSIP Number:

Gross Proceeds:

Bartering:


Stocks and Bonds:





Description:





Original document

777 28667225 24G

09-02-2009

172967101


0.00

0.00

$429.00

0.00

0.00

0.00

0.00

100 CITIGROUP INC

No Second Notice

0000000000000




SCOTTRADE INC


ST LOUIS, MO 63131-0000

Recipient:

https://lal .www4.irs.gov/semail/servlet/FileDownload 05/13/2014


Recipient's Identification Number:

DOUG ELLIS

7904 E 127TH TER


Submission Type:

Account Nurnbe r:


CUSIP Number:

Gross Proceeds:

Bartering:

Federal Income Tax-Withheld:

Stocks and Bonds:



9419


Unrealized Profit or (Loss) 12/31 current Year:

Description:





Page 5 of 15

Original document

777 28667225 24G

09-02-2009

316773100

Gross pr6ceeds minus comml.ssions and option premiums

0.00

0.00

$492.00

0.00

0.00

0.00

0.00

50 FIFTH THIRD BANCORP

No Second Notice

0000000000000




SCOTTRADE INC


ST LOUIS, MO 63131-0000


DOUG ELLIS

7904 E 127TH TER


Submission Type:

Account Number:


CUSIP Number:

Gross Proceeds:

Bartering:


Stocks and Bonds:





Description:





Original document

777 28667225 24G

10-20-2009

313400301


0.00

0.00

$111.00

0.00

0.00

0.00

0.00

100 FEDERAL HOME LOAN MTG CORP VTG C

No Second Notice

0000000000000



https://lal. www4.irs.gov/semail/servlet/FileDownload 05/13/2014

Wage and Income Transcript Page 6 of 15


SCOTTRADE INC


·sT LOUIS, MO 63131-0000


DOUG ELLIS

7904 E 127TH TER


Submission Type:

Account Number:


CUSIP Number:

Gross Proceeds:

Bartering:


Sto.cks and Bonds:





Description:





Original document

777 28667225 24G

11-09-2009

749227104

Gross procc,eds minus commissions and option premiums

0.00

0.00

$157.00

0,00

0.00

0.00

0.00

100 RAIT FINANCIAL TRUST

No Second Notice

0000000000000




SCOTTRADE INC


ST LOUIS, MO 63131-0000

Recipient: Recipient's Identification Number:~9419

DOUG ELLIS

7904 E 127TH TER


Submission Type:

Account Number:

Date of Sale or Ex~hange:

CUSIP Number:

Gross Proceeds:

Bartering:


Stocks and Bonds:





Description:

Original document

777 28667225 24G

11-09-2009

7591EP100

Gross proceeds minus commissions and option premiums 0.00

0.00

$159.00

o.oo 0.00

0.00

0.00

35 REGIONS FINANCIAL

https://lal .www4.irs.gov/semail/servlet/FileDownload 05/13/2014



Number.of Shares Exchanged:



Page 7 of 15

No Second Notice

0000000000000




SCOTTRADE INC


.ST LOUIS, MO 63131-0000

Recipient: Recipient's Identification Number:111111-9419 DOUG ELLIS

7904 E 127TH TER


Submission Type:

. Account Number:


CUSIP Number:

Gross Proceeds:

Bartering:


Stocks and Bonds:





Description:





Original document

777 28667225 24G

11-09-2009

852061100


0.00

0.00

$228.00

o.oo 0.00

0.00

0.00

80 SPRINT NEXTEL

No Second Notice

0000000000000




SCOTTRADE INC


ST LOUIS, MO 63131-0000

Recipient: Recipient's Identification Number:--9419

DOUG ELLIS

7904 E 127TH TER


Submission Type:

Account Number:


CUSIP Number:

Gross Proceeds:

Original document

777 28667225 24G

11-09-2009

760174102


https ://lal. www4.irs.gov/semail/servlet/FileDownload 05/13/2014

Wage and lncome Transcript

Bartering:


Stocks and Bonds:





Description:





Page 8 of 15

0.00

0.00

$382.00

0.00

o.oo 0.00

o.oo 25 RENTRAK CORP

No Second Notice

0000000000000




SCOTTRADE INC


ST LOUIS, MO 63131-0000

Recipient: Recipient's Identification Number: lllllt9419 DOUG ELLIS

7904 E 127TH TER


Submission Type:

Account Number:


CUSIP Number:

Gross Proceeds:

Bartering:


Stocks and Bonds:





Description:





Original document

777 28667225 24G

11-09-2009

55405Wl04


0.00

0.00

$407.00

0.00

0.00

0.00

0.00

25 MYR GROUP INC DEL COM COM

No Second Notice

0000000000000




SCOTTRADE INC


ST LOUIS, MO 63131-0000

Recipient: Recipient's Identification Number: 11111-9419 DOUG ELLIS



7904 E 127TH TER


Submission Type:

Account Number:


CUSIP Number:

Gross Proceeds:

Bartering:

Federal I·ncome Tax Withheld:

Stocks and Bonds:





Description:





Page 9 of 15

Original document

777 28667225 24G

11-09-2009

156431108


0.00

0.00

$163.00

0.00

0.00

0.00

0.00

50 CENTURY ALUM CO

No Second Notice

0000000000000

Loss can be .taken on tax return



SCOTTRADE INC


ST LOUIS, MO 63131-0000

. Recipient: Recipient's Identification Number: ~9419

DOUG ELLIS

7904 E 127TH TER


Submission Type:

Account Number:


CUSIP Number:

Gross Proceeds:

Bartering:


Stocks and Bonds:





Description:





Original document

777 28667225 24G

11-12-2009

039666102


0.00

0.00

$642.00

0.00

0.00

0.00

0.00

25 ARCSIGHT INC COM

No Second Notice

0000000000000



Payer:

https://lal.www4.irs.gov/semail/servlet/FileDownload 05/13/2014

Wage and lncome Transcript 1~age I u or D

Payer's Federal Identification Number (FIN): 860381976

SCOTTRADE INC

12800 CORPORATE HtLL 5TH FL

S! LOUIS, MO 63131-0000


DOUG ELLIS.

7904 E 127TH TER


Submission Type:

Account Number:


CUSIP Number:

Gross Proceeds:

Bartering:


Stocks and Bonds:





Description:





Original document

777 28667225 24G

11-24-2009

099469504

Gross proceeds minus commissions and option premituns

0.00

U.00

$128.00

0.00

0.00

0.00

o.oo 100 BOOTS & COOTS WELL CONTROL-NEW

No Second Notice

0000000000000




SCOTTRADE INC


ST LOUIS, MO 63131-0000


DOUG ELLIS

7904 E 127TH TER


Submission Type:

Account Number:


CUSIP Number:

Gross Proceeds:

Bartering:


Stocks and Bonds:





Description:


Original document

777 28667225 24G

11-24-2009

269246104


0.00

0.00

$156.00

0.00

0.00

0.00

0.00

100 ETRADE FINANCIAL CORP

No Second Notice

https://lal.www4.irs.gov/semail/servlet/FileDownload 05/13/2014

Wage and Income Transcript l'age 11 ot I.'.)

Nwnber of Shares Exchanged: 0000000000000


Recipient Ind.icator: Loss can be taken on tax return



SCOTTRADE INC


ST LOUIS, MO 63131-0000

Recipient: Recipient's Identiftcation Number: ~9419.

DOUG ELLIS

7904 E 127TH TER


Submission Type:

Account Number:


CUSIP Number:

Gross Proceeds:

Bartering:


Stocks and Bonds:





Description:





original document

777 28667225 24G

11-24-2009

131476103


0.00

0.00

$425.00

0.00

0.00

0.00

0.00

25 CALUMET SPLTY PD

No Second Notice

0000000000000




SCOTTRADE INC


ST LOUIS, MO 63131-0000


DOUG ELLIS

7904 E 127TH TER


Submission Type:

Account Number:


CUSIP Number:

Gross Proceeds:

Bartering:

Original document

777 28667225 24G

11-25-2009

172967101


0.00

https://la 1. www4.irs.gov/semail/servlet/FileDownload 05/13/2014



Stocks and Bonds:

Aggregate Profit or (Loss),




Description:


Number of Shares Excha.nged:



Page 12 of 15

0.00

$836.00

o.oo 0.00

0.00

0.00

200 CITIGROUP INC

No Seoohd Notice

0000000000000




SCOTTRADE INC


ST LOUIS, MO 63131-0000


DOUG ELLIS

7904 E 127TH TER


Submission Type:

Account Number:


CUSIP Number:

Gross Proceeds:

Bartering:


Stocks and Bonds:





Description:





Original document

777 28667225 24G

11-27-2009

835460106


0.00

0.00

$855.00

0.0Q

0.00

0.00

0.00

100 SONIC SOLUTIONS

No Second Notice

0000000000000




SCOTTRADE INC


ST LOUIS, MO 63131-0000


DOUG ELLIS

7904 E 127TH TER

https://la 1. www4.irs.gov/semail/servlet/FileDownload 05/13/2014



Submission Type:

Account Number:


CUSIP Number:

Gross Proceeds:

Bartering:


Stocks and Bonds:





Description:

·second Notice Indicator:




,(- Page 13 of 15

Original document

777 28667225 24G

12-04-2009

002083103


0.00

0.00

$169.00

0.00

o.oo o.oo 0.00

60 ATS MED INC

No Second Notice

0000000000000




SCOTTRADE INC


ST LOUIS, MO 63131-0000

Recipient: Recipient's Identification Nurnber:~9419

DOUG ELLIS

7904 E 127TH TER


Submission Type:

Account Number:


CUSIP Number:

Gross Proceeds:

Bartering:


Stocks and Bonds:





Description:





Original document

777 28667225 24G

12-04-2009

284902103


0.00

0.00

$402.00

0.00

0.00

0.00

0.00

30 ELDORADO GOLD CORPORATION - NEW

No Second Notice

0000000000000


Form 1098 Mortgage Interest Statement

Recipient/Lender: Recipient's Federal Identification Number (FIN): 742291652

https://la I. www4.irs.gov/semail/servlet/FileDownload 05/13/2014


USAA FEDERAL SAVINGS BANK

PO BOX 205

WATERLOO, IA 50704-0205

Payer/Borrower: Payer's Social Security Number: ~9419

DOUGLAS MELLIS

7904 E 127TH TERRACE


Submission Type:

Account Number (Optional):

Mortgage Interest Received from Payer(s)/Borrower(s):

Points Paid on Purchase of Principal Residence:

Refund of Overpaid Interest:

Mortgage Insurance Premiums:

Form 1098 Mortgagelnterest Statement

Recipient/Lender: Recipient's Federal Identification Number (FIN): 746393739

USAA FEDERAL SAVINGS BANK

10750 MCDERMOTT FREEWAY

SAN ANTONIO, TX 78288-0544

Payer /Borrower.: Payer's Social Security Number: 111111111-9419 DOUGLAS MELLIS

7904 E 127TH TER


Submission Type:


Mortgage Interest Received from Payer(s)/Borrower(s):

Points Paid on Purchase of Principal Residence:

Refund of Overpaid Interest:

Mortgage Insurance Premiums:

Form 1099-INT


R-G FEDERAL CREDIT UNION

128 W MARKEY RD

BELTON, MO 64012-1722

Recipient: Recipient's Identification Number: 11111111-9419 DOUGLAS MELLIS

7904 E 127TH TERRACE


Submission Type:


Interest:

Tax Withheld:

https://lal. www4.irs.gov/semail/servlet/FileDownload

Page 14 of 15

Original document

0702112892

$6,271.00

0.00

o.oo o.oo

Original document

3207000000084190073

$1,951.00

0.00

0.00

0.00

Original document

31026-00

$16.00

0.00

05/13/2014


Savings Bonds:

Investmen·t Expense:

Interest Forfeiture:

Foreign Tax Paid:


' (! Page 15 of 15

0.00

0.00

0.00

0.00

No Second Notice

Form 1099-R Distributions from Pensions, Annuities, Retire or ProfitSharing Plans, IRAs, Insurance Contracts, etc.


AMERICAN CENTURY SERVICES LLC

TEFRA AGENT

4500 MAIN ST

KANSAS CITY, MO 64111-0000


DOUGLAS MELLIS

7904 E 127TH TER


sub.mission Type:


Distri.bution Code Value:

Distribution Code:

Distribution Code Value:

Distribution Code:

Tax Amount Undetermined Code:

Total Distribution Code:

SEP Indicator:

Tax Withheld:

Total Employee Contributions:

Unrealized Appreciation:

Other Income:

Gross Distribution:

Taxable Amount:

Eligible Capital Gains:

Original document

AAAM0092100009102514

Early Distribution, no known exception (in most cases, under age 59 1/2)

1

Not significant ·

Blank

Tax amount not determined

Total Distribution


IRA/SEP/SIMP box checked

0.00

0.00

0.00

0.00

$666.00

$666.00

0.00


1,1;:J;')i MISSOURI DEPARTMENT OF REVENUE 2L }ORM MQ-i 040 ~ INDIVIDUAL INCOME TAX RETURN-:-LONG FORM -· FOR CALENDAR YEAR JAN. 1-DEC. 31, 2009, OR FISCAL YEAR BEGINNING

Select Month ENDING Select Month Select Ye;

1!1!191::a11111.~ NAME AND ADDRESS

ISOFlWARE iY'1Jll1 VENDORCODE jlll ~ e

~ I SPOUSE'S SOCIAL SECURITY NUMBER f'Vr<f

NAME (LAST) (FIRST) M.I. ~ 0

£cc../s· L/c:?c:2,~ L,/J 5 /,?I D~g u,N

Exhibit D

SPOUSE'S (LAST) (FIRST) M.1. JR, SA uz o~""' THIS IS A 2-D BARCODE. DO NOT ERASE rt OR WRITE ON IT.

IN CARE OF NAME (ATTORNEY, EXECUTOR, PERSONAL REPRESENTATIVE, ETC.) COUNTY OF RESIDENCE SCHOOL DISTRICT NO. / 1'/ SELECT COUi,fTY '])1l-/($o iv' SELECT or TYPE SCHOC

PRESENT ADDRESS (INCLUDE APARTMENT NUMBER OR RURAL ROUTE) CITY, TOWN, OR POST OFFICE STATE I ZIPCODE -73 o~ ~/:2 ?r;q, /££ £/,:Jc·<£: "£A'Nov?ev ,/.JJ A> Gef ,t;J . 3.f'J

You may contri~ute to any one or all of the Children's la( Veterans I Eldarly Home ! Missouri e Workers' ® Childhood :; · Missouri §enornl ~ Atter trust fu~d~ on Lme 45. See pages 9--10 for ~~ Delivered Nallonal W•11<11• Memorial Lead ·, ... MIIHary a..... Rovonuo · 8o.il0ol a descnpl1on of each trust fund, as well as Meals Guard Testlll(I

Family R.... · · Re~eal

trust fund codes lo enter on Line 45. Relief

PLEASE CHECK THE APPR.OPRIATE BOXES THAT APPLY TO YOURSELF OR YOUR SPOUSE AS OF DECEMBER 31, 2009,

AGE 62 THROUGH 64 AGE 65 OR OLDEB BLIND 100'M! DISABLED !'!!ON-OBLIGATED SPOUSE D YOURSELF D YOURSELF D YOURSELF D YOURSELF 0 YOURSELF OsPOUSE DsPousE OsPousE D SPOUSE 0 SPOUSE

Yourself Spouse 1. Federal adjusted gross income from your 2009 federal return (See worksheet on page 6.) . 1Y ~7tVi00 1S I A\ !OD 2. Total additions (from Form MO-A, Part 1, Line 6) ......................... , ....... 2¥ O!OO 2S OiQO

L!J 3. Total income -Add Lines 1 and 2 ............................................. 3Y 0100 3S O!OO ~ 0 4. Total subtractions (from Form MO-A, Part 1, Line 14) .............................. 4Y 0100 4S 0100 0 ~ 5. Missouri adjusted gross income - Subtract Line 4 from Line 3. . ................... · .. SY O!OO 5S "1 O!QO

6. Total Missouri adjusted gross income - Add columns SY and SS. . .. .. . . .. .. .. . .. . .. .. . . .. .. . .. . .. .. I a ;\;l 7.Z f:: 00 7. Income percentages - Divide columns 5Y and 5S by total on Line 6. (Musi equal 100%) ... 7Y 1()0 % 78 j) 0 %

8. Pension and Social Security/Social Security disability exemption (from Form MO-A, Part 3) ............... 8 o/00 9. Mark your filing status box below and enter the a:~~iate exemption amount on Line 9. '

I 1B A.cSfijgje $2,1QQ (See Bax B befare cb"' ·njp D E. Married filing separate (spouse D B. Claimed as a dependent on another person's federal NOT filing)-$4,200

tax return -$0.00 0 F. Head of household-$3,500 D C. Married filing joint federal & combined Missouri -$4,200 D G. Qualifying widow(er) with

9 ·:2. IPO 100 D D. Married filing separate - $2,100 dependent child-$3,500 10. Tax from federal return <Do not enter fedP.ral income tax withheld.)

_!'.,deral Form 1040 Line 55 minus Lines 45, 63, 64a, 66, 67 · d amounts from Forms 8801 and 8885 on Line 70 Federal Fonn 1040A, Line 35 minus Line 40, 41a, q;;s, and any alternative minimum tax included on Line 28

U') • Federal Fonn 1040EZ, Line 11 minus Line 8 and 9a ........................... 10 /t;~/i uu ~ 11. Other tax from federal return - Attach copy of your federal return (pages 1 and 2). 11 ! uu § 12. Totaltax from federal return - Add Lines 1 O and 11. . ....................... 12 a-.2-11 uu ::>

13. Federal tax deduction- Enter amount from Line 12 not to exceed $5,000 for individual filer; I Cl w $10,000 for combined filers ................................................................ 13 /5.ll OD Cl Cl 14. Missouri standard deduction OR itemized deductions. ,Gingle or Married Filing Separate..:.. S5.~Head of z <t: Householi:J--,.. $8,350; married Filing a Combined Return or Qualifying Widow(er)-$11,400; If you are age 65 or U') older, ~lind. or claim~d a~~ dependent, see your federal r~ 7. If you claimed an additional standard z d:J. O 0 00 0 deduction or you are 1tem1zmg, see Form MO-A, Part 2, or orm MO- . . . • . . • . . . . . . . . . . . . . . . . . .. 14 ;=:

15. Number ol dependenls from Federal Fonn 1040 OR 1040A, Lin, Bo ~ I C. ADonot ::E (DO NOT INCLUDE YOURSELF OR SPOUSE.) . . . . . . . . . . . . . . . . . . . . . . . . . . . o X $1,200 = .. 15 0 00 nclude w r:.'J 16. Number of dependents on Line 15 who are 65 years of age or older and do not I yourself

~ or receive Medicai~ or slate funding_ (DO NOT INCLUDE YOURSELF OR SPOUSE) o X $1,000 = .. 16 0 00 spouse.

17. Long-term care insurance deduction .......................................................... 17 0 00 18. Health care sharing ministry deduction : ....................................................... 18 0 00 19. Total deductions -Add Lines 8, 9, 13, 14, 15, 16, 17, and 18 ...................................... 19 rr;,... , 00 20. Subtotal - Subtract Line 19 from Line 6 ....................................................... 20 I i.'10 3 00 21. Multiply Line 20 by appropriate percentages(%) on Lines 7Y and 7S .................. 21Y ,'f) o 00 218 II\ o 00 22. Enterprise zone or rural empowerment zone income modification .................... 22Y ~ 00 228 00 23. Subtract Line 22 from Line 21. Enter here and on Line 24 ........................... 23Y I J-903 00 23S ~I 0 00

) Yourself Spouse

24. Taxable income amount from Lines 23Y and 23S .. . . . . . . . .. . . . . . . . . . . . . .. . . . . .. .. i-='2:..:.4,:--Y1-----_,1'-'1_=-lf1!..J'/ 11"'-L~+-i(:):"":a[,Je1-.=.2..:.:4S=-i----'l~"--~Q~· 25. Tax. (See tax table on M::~ 'JA nf_ th~ instructions' . . . . . . . . . . . . . . . . i-.:;2;.:;.5Y"-f----.L7...,_V_,__,;l-,U~O• i..:::2;.:;.5S;:.+----i!-----4,.;o..l;t..lo 26. Resident credtt-{Attach Form MO-CR and other states' income tax return/sJ\ OR . . . . . . 26Y // r;" 00 26S 00

1--'--+------'-''-"'--'-...;...:..-t="-'--f---&'-----~.;..i

_ 27. Missouri income percentage - Enter 100% unless yciu are completing Form MO-NRI.

~ 1-

Attach Form MO-NRI and a copy of your federal return if less than 100%. Check the box if you or your spouse is a professional entertainer or a member of a professional athletic team.

0 YOURSELF O SPOUSE ................................... . 27Y /CCI % 27S % 28. Balance - Subtract Line 26 from Line 25; OR

Multiply Line 25 by percentage on Line 27. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Y 1/3 LI 00 28S 29. Other taxes (Check box and attach federal form indicated.) I

D Lump sum distribution (Form 4972) /

loo I

D Recapture of low income housing credit (Form 8611) . . . . . . . . . . . . . . . . . . . . . . . . 29Y CJ i 00 29S 30. Subtotal -Add Lines 28 and 29 ........................................ , . . . . . . 30Y ~ 3 fl ! 00 3_0S \ 31. Tota1Tax-Addlines30Yand30S ............................................................. 31 ~3<'/100

~ 32. MISSOURI tax wtthhel?-Attach Form W-2(s) and/or Form 1099(s) ...................................... 1-3=2 _____ 4...,· 1=~=+-1, 0"'-'0=-i @ 33. 2009 Missouri estimated tax payments (include overpayment from 2008 applied to 2009) ....................... 1-3_3 ______ 0"-+l.,..O-~ 34. Missouri tax payments for nonresident partners or S corporation shareholders -Attach Form M0-2NR. ....... 1-3=-4:...i-------O::-i.i .... 0;..1:0'--'

:;;; 35. Missouri tax payments for nonresident entertainers -Attach Form M0-2ENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 fJ i 00 .,, 1

1 00 ~ 36. Amount paid with Missouri extension of time to file (Form M0-60) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 ~ 37. Miscellaneous taxcredhs (from Form MO-TC, Line 13)-Attach Form MO-TC ..... , ...................... ,_3_7 _____ ~0--,...i1 _OD___,

~ 38. Property tax credit -Attach Form MO-PTS. .. .................................................... 1-3c..c8+------o"'--+-! 0.;:..0;:;;..i c.. 39. Total oavments and credits -Add Lines 32 throuoh 38 ...................... , . . .. . .. . . .. . . . . .. . . . .. . 39 q..:.,_2 i 00-

Skip Lines 40-42 if you are not filing an amended return. i,00 g§ 40. Amount paid on original return ........................................................ , ......... 1-4""0'-+--------+-='-='-l

i:! 41. Overpayment as shown (or adjusted) on original return ............................. ·,..· ~· ._. _ .. _._. ~· ._. ~· ._. ~· .,_.-t---4_1 ~----c:--~! 0~0"'-1 i:g INDICATE REASON(S) FOR AMENDING. M, MI D DI Y Y /J'/ /; @ DA. Federal audit .................................. Enter date of IRS report. 1--.._1.._.___,1--~ / (//,/I ~ DB. Net operating loss carryback .. , ....................... Enter year of loss. ~ DC. Investment tax credit carryback ....................... Enter year of credtt. c:c DD. Correction other than A, B, or C ... Enter date of federal amended return,~ filed. 1 1 ~~~~~-'---+---.------~---1

42. Amended Return - total oavments and credits. Add Line 40 to Line 39 or subtract Line 41 from Line 39 ...... . 42 iOO 43. If Line 39, or~ amended return, Line 42, is larger than Line 31, enter difference

(amount of OVERPAYMENT) here .......... '. ................................................... .

'

43 loo 44. Amount of Line 43 to be applied to your 201 O estimated tax ......................................... . 44 /oo

i loo 100

,'!/~Children's ',..-Velerans I Elderly !Missoorl eWorkers' (.;:?.l.CMdhood •· ~ Hane National Memorial V Lead

Delivered Guard Testing ' Meals

Missouri ~•neral _ - " Aner Addi. Trusl Addi. Trusl Mi~•ry Revenue ~ Schoa Fund Code Fund Code Fanily • ~ Aetreal (See lnsb'.) (See Instr.) Aeiel _I __ I_

45. Enter the amount of g: your donation in the o trust fund boxes to the ~ right. See instructions 5 for trust fund codes. loo loo loo :oo !oo !00 ioo loo loo !oo

~ 46. OverpiJ.yment to be refunded to you. Subtract Lines 44 and 45 from Line 43 a: and enter here. Sign below and mail return to: Department of Revenue, g PO Box 500, Jefferson City, MO 65106-0500 ........................................... REFUND ~ 47. If Line 31 is larger than Line 39 or Line 42, enter the difference (amount of UNDERPAYMENT) here .......... .

46 00 47 00

fu 48. Underpayment of estimated tax penalty-Attach Form M0-2210. Enter penalty amount here .............. . a: 1-'-'-+-------~-=-i 48 00 49. Total amount due -Add Lines 47 and 48 and enter here. Sign below and mail return and payment to:

Department of Revenue, PO Box 329, Jefferson City, MO 65107-0329. Please write your social securtty number(s) and daytime phone number on your check or money order (U.S. funds only). Make payable to Missouri Department of Revenue ........................................... AMOUNT YOU OWE ,_4_9_,___ ____ 1 2_L..O""'Oc.., If you pay by check, you authorize the Department of Revenue to process the check electronically. Any returned check may be presented again electronically.

100

Under penalties of pequry, I declare lhal I have examined !his relum, in.duding accooipanying schedules and slalemenls, and to !he best of my knol'.iedge and belief tt is true, correct, and cooiplete. Dedaratioo of preparer (olher lhan taxpayer) Is based on all informatioo of Ylhich he/she has arrt knowledge. As provided In Chapter 143, RSMo, a penalty of up to $500 shall be Imposed on any individual who files a tri\idous relum. I also declare under penalties of perjury that I employ no illegal orunaulhorized aliens as defined under federal law and Iha! I am not eligible for any tax exemptioo, credil or abatement if I employ such aliens.

~ I authorize the Director of Revenue or delegate to discuss my return and attachments I E-MAIL ADDRESS· I PAEPAAER'STELEPHONE

~ with the preparer or any member ot the preparers firm. 0 YES O NO ( ---) -------

~ SIGNATURE DATE PAEPAAEA'SSIGNATURE

*1-:s-;;C,2=1-~~p'~:'z_., _L;??,::._::?7!:_--~-~~-~~2.·--~~~~2~~/l~l'.'.}L_-f-_-=--=--=--=--=--=--=--=--=--=--=--=---_l_---.-~-~ SPOUSE'S Sl~A TUflE (If li/ing combined, BOTH must sign) DAYTIME TELEPHONE PREPAAEA'S ADDRESS AND ZIP CODE I DA-TE ___ _

( ~/&,) F'f'0 - 9"'8'6h

FEIN, SSN, OR PTIII

MO 860-1094 (09-2009) This form is available,uoon reauest in alternative accessible format(sl.

If Missouri taxable income from Form M0-1040, Line 24, is less than $9,000, use the table to figure tax; if more than $9,000, use worksheet below or use the onUne tax oaloulator at www.dor.mo.gov/lax

If Line 24 is If Line 24 is ff Line 24 ls If Line 21 ls If Line 24 ls ff Line 24 ls BUI But ut ut But But

At less Your At less Your At lesa . Your At las~ Your Al less V<>ur At less Your feast than taxis least than tax Is le11st tMn tax Is least than tax ls least than t xis least than tax:11,1

0 100 $ 0 1,500 1,600 $ 26 3,000 3,100 $ 62 4,500 4,600 $109 6,000 6,100 $167 7,600 7,600 $238 100 200 2 1,600 1,700 28 3,100 3,200 66 4,600 4,700 113 6,100 6,200 172 7,600 7,700 243 200 300 4 1,700 1,800 30 3,200 3,300 68 4,700 4,800 116 6,200 6,300 176 7,700 7,800 248 300 400 5 1,800 1,900 32 3,300 3,400 71 4,800 4,900 120 6,300 6,400 181 7,800 7,900 263 400 500 7 1,900 2,000 34 34 0 .3,600 74 4 900 5000 1 3 6400 6600 18 7 900 8000 268 500 600 8 2,000 2,100 36 3,600 3,600 77 6,000 6,100 127 6,500 6i500 HiO 8,000 8,100 263 600 700 10 2,100 2,200 39 3,600 3,700 80 5,100 5,200 131 6,600 6,700 194 8,100. 8,200 268 700 800 11 2,200 2,300 41 3,700 3,800 83 5,200 5,$00 135 6,700 6,800 199 8,200 8,300 274 800 900 13 2,300 2,400 44 3,800 3,900 86 5,300 5,400 139 6,800 6,900 203 8,300 8,400 279 900 1,000 14 2,400 2,500 46 3,900 4000 89 6400 6,600 143 6,900 7,000 208 8,400 8,500 286

1,000 1,100 16 2,500 2,600 49 ,000 4,100 92 6,500 5,600 147 7,000 7,10 13 8,600 8,600 290 1,100 1,200 18 2,600 2,700 51 4,100 4,200 95 6,600 6,700 161 7,100 7,200 218 8,600 8,700 296 1,200 1,300 20 2,700 2,800 54 4,200 4,300 99 5,700 6,800 165 7,200 7,300 223 8,700 8,800 301 1,300 1,400 22 2,800 2,900 56 4,300 4,400 102 5,800 6,900 169 7,300 7,400 228 8,800 8,900 307 1,400 1,500 24 2,900 3,000 59 4400 4600 106 6 900 6000 163 7,400 7,600 233 8900 9000 31'2

Yourself SgQuse Exam~,~ 9; 0 31

Missouri taxable income (Line 24) ...... $ /:) .. t/tJ1 $ $ 12,000 If more th~n $9,000,

tax Is $315 PLUS 6% of Subtract $9,000 .................. - $ 9,000 - $ 9,000 - $ 9,000 excess over $9,000.

Difference ....................... = $ 3rtJJ = $ Round to nearest whole = $ 3,000 dollar and enter on Form Multiply by 6% ................... X 6% X 6% X 6% 1040, Page 2, Line 25.

Tax on income over $9,000 ......... = $ 2'}'1ll! = $ = $. 180 Add $315 (tax on first $9,000) ....... + $ 315 + $ 315 + $ 315

TOTAL MISSOURI TAX ............ = $ 5'/1,li = $ $ 495 = A separate tax must be computed for you and your spouse.

Complete this worksheet if you included health insurance premiums paid as an itemized deduction or had health insurance premiums withheld from your social security benefits. .

If you had premiums withheld from your social security benefits, complete Lines 1 through 4 to determine your taxable percentage of social security income and the corresponding taxable portion of your health insurance premiums included in your taxable income.

1. Enter amount from Line 14a (federal Form 1040A) or 20a (federal Form 1040). If $0, skip to Line 6 and enter your total health insurance premiums paid.

2. Enter amount from Line 14b (federal Form 1040A) or 20b (federal Form 1040).

3. Divide Line 2 by Line 1

4. Enter the health insurance premiums withheld from your social security income.

5. Multiply the amounts on Line 4Y and 45 by the percentage on Line 3.

6. Enter the total of all other health insurance premiums paid, which were no.t included in 4Y or 45.

7. Add the amounts from Lines 5 and 6. If you itemized on your federal return and your federal itemized deductions included health insurance premiums as medical expenses, go on to Line 8. If not, enter amounts from 7Y and 75 on Line 11 of Form MO-A.

8. Add the amounts from 7Y and 75.

9. Divide Line 7Y and 75 by the total found on Line 8 ..

10. Enter the amount from Federal Schedule A, Line 1.

11. Enter the amount from Schedule A, Line 4.

12. Divide Line 11 by Line 10 (round to full percent).

13. Multiply Line 8 by percent on Line 12.

14. Subtract Line 13 from Line 8.

15 . Multiply Line 14 by the percentages found on Lines 9Y and 95. Enter the amounts on Line 1 SY and 1 SS of this worksheet on Line 11 of Form MO-A.

1. ___ _

2. ___ _

3. ____ %

Yourself Spouse 4Y. ___ _ 45. ___ _

SY. ___ _ 55. ___ _

6Y. ___ _ 65. ___ _

7Y. 75. ----

8.

9Y. 9S. ___ _

10.

11.

12.

13.

14.

15Y. 155. ----

~~;:;;'/!'-~'.,,, MISSOURI DEPARTMENT OF RI:. .-..::1\IUE

f(°tlr J) INCREASE TO STANDARD DEDUCTION '-~~ FOR CERTAIN FILERS .

L.U5 SPOUSE'S NAME

2009 FORM

MO-l

2. If you are over 65 or plind, enter the amount reported on Line 5 of federal Schedule L. .................................................... .

3. Enter the amount of any net disaster loss included in your standard deduction and reported on Line 6 of federal Schedule L. ......................... .

4. Enter the amount of state and focal real estate taxes included in your standard deduction and reported on Line 9 of federal Schedule L. ................. .

5. Enter the amount of any new motor vehicle taxes included in your standard deduction and reported on Line 20 of federal Schedule L. ................ .

6. Add the amounts shown on Lines 1 through 5 and report the total here and on Form M0-1040 Line 14. . ......................................... .

.#"~~~~ «t~/)J MISSOURI DEPARTMENT OF REVENUE 'ii..~i-"" HOME ENERGY AUDIT EXPENSE

2009 FORM

MO-HEA NAME OF TAXPAYER

ADDRESS

L

SPOUSE'S SOCIAL SECURITY NO,

1. :=,; 7 Oo 00

2. 0 00

3. 0 00

4. 501;;1 oo

5. () 00

6. &.::200100

Beginning January 1, 2009, any taxpayer who paid an individual certified by the Department of Natural Resources to complete a home energy audit may deduct 100% of the costs incurred for the audit and the implementation of any energy efficiency recommendations made by the auditor. The maximum yearly subtraction may not exceed $1,000, for a single taxpayer or a married couple filing a combined return. For all years in which you incur expenses, the maximum total subtraction you may claim is $2,000. To qualify for the deduction, you must have incurred expenses in the year you are filing a claim, and the expenses incurred must not have been excluded from your federal adjusted gross income or reimbursed through any other state or federal program.

• Report the name of the auditor who conducted the audit • Summarize each of the auditor's recommendations •·Enter the total amount paid to implement the energy efficiency

recommendations on Lme B • Attach applicable receipts

NAME OF AUDITOR

1.

2.

3.

4.

5.

• Report the auditor's certification number • Enter the amount paid for the audit on Line A • Enter the total amount paid for the audit and any implemented

recommendations on Lrne C • Attach completed MO-HEA and receipts to Form M0-1040

AUDITOR CERTIFICATION NUMBER

loo A. Amount paid for audit ...................................... : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . '-'A-'-. 1-----------,i.......;__i 8. Amount paid to implement recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B. 00 -----------------'-~ C. Total Pmd-Add Lines A and Band enter here. Enterline C or $1,000, whichever is less, on Line 13 of Form

MO-A. if you are filing a combined return, you may split the amount reported on Line 13 between both taxpayers.... C. 00

) , I

/(~t'!'\, MISSOURI bEPARTMENT OF REVENUE K b )J CREDIT FOR INCOME TAXES PAID TO }i;;~~::? OTHER STATES OR POLITICAL SUBDIVISIONS

2009 AttaohrnenfSequence No. 1040-03

FORM

MO-CR Complete this form for you and your spouse, it you and/or your spouse have income from another state or political subdivision. If you had multiple credits, complete a separate form for each

• Attach a copy of all Income tax returns for each state or polltloal subdlvl&lon.

state or political subdivision. YOUR NAME

1. Claimant's Iota! adjusted gross income (Form M0-1040, Line SY and/or Line 5S)



Form M0-1040 Line25Y and/or line 25S ....................................... . USE TWO LETTER ABBREVIATION FOR STATE OR NAME OF POLfflCAL SUBDIVISION. See table on back.

i 2 ! 00

STATE OF:

3. Wages and commissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-__ _.'.UL;;W~~~__:=:::==:====--i.~ 3 iOO 00 4. Other (describe nature) ..................... . 4

5. Total -Add Lines 3 and 4. . .................................................. . 5 00 6. Less: related adjustments (from Federal Form 1040A, Line 20, OR Federal Form 1040, Line 36) .. 1-----....,..._....c;.Lt;,.+.:~~-l--...:::;:======:__~ 6 00

00 7. Net amounts - Subtrac! Line 6 from Line 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,__ __ __.r...£..L..J:t...l~+-!.......J.--=:====--_:_~ 7 % 8. Percentage of your income taxed - Divide Line 7 by Line 1. .. ....................... . 8

9. Maximum credft - Multiply Line 2 by percentage on Line 8 ........................... . 9 0 10. Income tax you paid to another state or polttical subdivision. This is not tax withheld.

The income tax is reduced by all credits, except withholding and estimated tax. . . . . . . . . . . . . . 1-----'-~~--+---+-------'--~ 6 00 10 - 00 11. Credtt- Enter the smaller amount of Line 9 or Line 10 here and on Form M0-1040,

Line 26Y or Line 26S. (If you have muttiple credits, add the amounts on Line 11 from each Form MO-CR before enterin on Form M0-1040 ................. . //5100 11

MO 860-1095 (11-2009) For Privacy Notice see the instructions

,,f~t\ MISSOURI DEPARTMENT OF REVENUE ft ,G~ JJ CREDIT FOR INCOME TAXES PAID TO \;i.i.~::? OTHER STATES OR POLITICAL SU8DIVISIONS

Complete this form for you and your spouse, it you and/or your spouse have income from another state or political subdivision. If you had multiple credits, complete a separate form for each state or political subdivision.


FORM

MO-CR • Attach a copy of all income tax returns for each state or

political subdivision.


00

YOUR NAME YOUR SOCIAL SECURITY NO. YOUR SPOUSE'S NAME SPOUSE'S SOCIAL SECURITY NO.


2. Claimant's Missourt income tax Form M0-1040 Line 25Y and/or Line 25S ....................................... .

USE TWO LETTER ABBREVIATION FOR STATE OR NAME OF POLITICAL SUBDIVISION. See table on back.

3; Wages and commissions ..................................................... . 4. Other (describe nature) ..................... . 5. Total - Add Lines 3 and 4. . .................................................. . 6. Less: related adjustments (from Federal Form 1040A, Line 20, OR Federal Form 1040, Line 36) .. 7. Net amounts - Subtract Line 6 from Line 5. . ..................................... . 8. Percentage of your income taxed - Divide Line 7 by Line 1. . ........................ . 9. Maximum credit - Multiply Line 2 by percentage on Line 8 ........................... .

. 10. Income tax you paid to another state or political subdivision. This is not tax withheld. The income tax is reduced by all credits, except withholding and estimated tax. . ........... .

11. Credit - Enter the smaller amount of Line 9 or Line 10 here and on Form M0-1040, Line 26¥ or Line 26S. (If you have multiple credits, add the amounts on Line 11 from each Form MO-CR before enterin on Form M0-1040 ................. .

i 00 STATE OF:

: 00 00 00 00 00 % 00

00

00

' 2 ioo

STATE OF:

3 i 00 4 i 00 5 iOO 6 i 00 7 ; 00 8 % 9 00

10 00

11 00

administrative hearing - missourii missouri department of revenue 2009 form m0-1040 'zj/...

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