indiana 2012 barcode test #14 2012...

INDIANA 2012 Barcode TEST #14

2012 IT-40PNR

Test Scenario 14 – TEST A CARR Test Scenario 14 Taxpayer: TEST A CARR SSN: 400‐00‐4051 Spouse: MERCEDES X CARR SSN: 400‐00‐4052 Test Scenario 14 includes the following forms: Form IT‐40PNR Schedule A Schedule D Schedule F Schedule G Schedule H Schedule IN‐DEP Schedule CT‐40PNR Schedule IN‐BAR 4 Form W‐2’s

Indiana BC Test 14 of 17 10/19/2012

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If fi ling for a fi scal year, enter the dates (see instructions) (MM/DD/YYYY):

from to:

Indiana Part-Year or Full-Year Nonresident Individual Income Tax Return 2012

FormIT-40PNR

State Form 472(R11 / 9-12)

Due April 15, 2013

Spouse’s Social Security Number

Place “X” in box if you are married fi ling separately.

Your Social Security Number

Place “X” in box if applying for ITIN Place “X” in box if applying for ITIN

School corporation number (see pages 58 and 59 )

Present address (number and street or rural route)

Enter below the 2-digit county code numbers (found on the back of Schedule CT-40PNR) for the county where you lived and worked on January 1, 2012.

County where spouse lived

County where spouse worked

County where you lived

County where you worked

1. Complete Schedule A fi rst. Enter here the amount from Section 3, line 37B, and encloseSchedule A ______________________________________________________ Indiana Income 1 .00

2. Enter amount from Schedule B, line 6, and enclose Schedule B __________ Indiana Add-Backs 2 .003. Add line 1 and line 2 _____________________________________________________________ 3 .004. Enter amount from Schedule C, line 12, and enclose Schedule C ________ Indiana Deductions 4 .005. Subtract line 4 from line 3 ____________________________________ Indiana Adjusted Income 5 .006. You must complete Schedule D. Enter amount from Schedule D, line 7,

and enclose Schedule D _______________________________________ Indiana Exemptions 6 .007. Subtract line 6 from line 5 _______________________________________State Taxable Income 7 .008. State adjusted gross income tax: multiply line 7 by 3.4% (.034)

(if answer is less than zero, leave blank) _____________________ 8 .009. County tax. Enter county tax due from Schedule CT-40PNR

(if answer is less than zero, leave blank) _____________________ 9 .0010. Other taxes. Enter amount from Schedule E, line 4 (enclose sch.) 10 .0011. Add lines 8, 9 and 10. Enter total here and on line 16 on the back _____________ Indiana Taxes 11 .00

City State Zip/Postal code

Foreign country 2-character code (see pg. 6 )

Round all entries

Your fi rst name Initial Last name

If fi ling a joint return, spouse’s fi rst name Initial Last name

Suffi x

Suffi x

��15712111594

400 00 4051 400 00 4052

TEST A CARR

MERCEDES X CARR

5400 OAKWOOD ST

BIRMINGHAM AL 35228

9999

00 49 00 00

26400

26400

26400

3549

22851

777

95

872


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12. Enter credits from Schedule F, line 8 (enclose schedule) ____ 12 .0013. Enter offset credits from Schedule G, line 7 (enclose schedule) 13 .0014. Automatic Taxpayer Refund credit

Enter $ XXX if joint fi ling but only one is eligible (leave blank if not eligible; see instructions on page XX )_______________ 14 .00

15. Add lines 12, 13 and 14 ____________________________________________ Indiana Credits 15 .0016. Enter amount from line 11 ___________________________________________ Indiana Taxes 16 .0017. If line 15 is equal to or more than line 16, subtract line 16 from line 15 (if smaller, skip to line 24) 17 .0018. Amount from line 17 to be donated to the Indiana Nongame Wildlife Fund _______________ 18 .0019. Subtract line 18 from line 17 __________________________________________ Overpayment 19 .0020. Amount from line 19 to be applied to your 2013 estimated tax account (see instructions on page 10 ).

Enter your county code county tax to be applied $ a .00Spouse’s county code county tax to be applied $ b .00Indiana adjusted gross income tax to be applied _________ $ c .00Total to be applied to your estimated tax account (a + b + c; cannot be more than line 19) _____ 20d .00

21. Penalty for underpayment of estimated tax from Schedule IT-2210 or IT-2210A (enclose sch.) __ 21 .0022. Refund: Line 19 minus lines 20d and 21. Note: If less than zero, see line 24 instructions Your Refund 22 .0023. Direct Deposit (see page 11 ) c. Type: Checking Savings Hoosier Works MC

a. Routing Number

b. Account Number

d. Place an “X” in the box if refund will go to an account outside the United States

24. If line 16 is more than line 15, subtract line 15 from line 16. Add to this any amount on line 21(see instructions on page 11 ) ____________________________________________________ 24 .00

25. Penalty if fi led after due date (see instructions) _______________________________________ 25 .0026. Interest if fi led after due date (see instructions) _______________________________________ 26 .0027. Amount Due: Add lines 24, 25 and 26 ______________________________ Amount You Owe 27 .00

Do not send cash. Please make your check or money order payable to: Indiana Department of Revenue.

Sign and date this return after reading the Authorization statement on Schedule H. You must enclose Schedule H.

_____________________________________________________ _________________________________________________Your Signature Date Spouse’s Signature Date

• If enclosing payment mail to: Indiana Department of Revenue, P.O. Box 7224, Indianapolis, IN 46207-7224. • Mail all other returns to: Indiana Department of Revenue, P.O. Box 40, Indianapolis, IN 46206-0040.

��15712121594

867

777

1644

872

772

772

772


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Schedule A Section 1: Income or Loss(Complete Proration, Section 2 and Section 3 on back)

Name(s) shown on Form IT-40PNR Your Social Security Number

Section 1: Income or (Loss) Enter in Column A the same income or loss you reported on your 2012 federal income tax return, Form 1040, 1040A or 1040EZ (except for line 19B and/or a net operating loss carryforward on line 20B; see instructions). Round all entries.

Line-by-line instructions begin on page 13.

1. Your wages, salaries, tips, commissions, etc _____________ 1A .00 1B .002. Spouse’s wages, salaries, tips, commissions, etc _________ 2A .00 2B .003. Taxable interest income _____________________________ 3A .00 3B .004. Dividend income __________________________________ 4A .00 4B .005. Taxable refunds, credits, or offsets of state

and local taxes from your federal return ________________ 5A .00 5B .006. Alimony received __________________________________ 6A .00 6B .007. Business income or loss from federal Schedule C or C-EZ _ 7A .00 7B .008. Capital gain or loss from sale or exchange

of property from your federal return ____________________ 8A .00 8B .009. Other gains or (losses) from Form 4797 ________________ 9A .00 9B .00

10. Total IRA distribution ________________________________ 10A .00 10B .0011. Total pensions and annuities _________________________ 11A .00 11B .0012. Net rent or royalty income or loss reported on

federal Schedule E ________________________________ 12A .00 12B .0013. Income or loss from partnerships _____________________ 13A .00 13B .0014. Income or loss from trusts and estates _________________ 14A .00 14B .0015. Income or loss from S corporations ____________________ 15A .00 15B .0016. Farm income or loss from federal Schedule F ____________ 16A .00 16B .0017. Unemployment compensation ________________________ 17A .00 17B .0018. Taxable Social Security benefi ts _______________________ 18A . 00 18B .0019. Indiana apportioned income from

Schedule IT-40PNRA ___________________________________________________________ 19B .0020. Other income reported on your federal return ____________ 20A .00 20B .00

List source(s). (Do not include federal net operating loss in Column B. See instructions on page 15 .)

21. Subtotal: add lines 1 through 20. _____________________ 21A .00 21B .00

Column AIncome from Federal Return

Column BIncome Taxed by Indiana

Schedule AForm IT-40PNRState Form 48719(R11 / 9-12)

EnclosureSequence No. 01

Page 1 of 22012

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TEST A & MERCEDES X CARR 400 00 4051

30400 26400

21400

200

100

52100 26400


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Schedule A Proration; Section 2: Adjustments to Income

Proration Section See instructions on page 15.

21C. Note: Nonresident military personnel see special instructions on page 15. and complete worksheet. ________________________________________________________ 21C .0021D. For all other individuals, divide the amount on line 21B by the amount on line 21A (see instructions

if either line 21A and/or 21B are less than zero). Please round your answer to a decimal followed by three numbers. Example: $3,100 ÷ $8,000 = .3875, which rounds to .388 (do not enter a number greater than 1.00). Enter result here and on Schedule D, line 6 _________________________ 21D .

Section 2: Adjustments to Income Note: Enter in Column A only those deductions claimed on your 2012 federal income tax return, Form 1040, 1040A or 1040EZ. Round all entries.

Line-by-line instructions continue on page 16.

22. Educator expenses (see instructions) _________________ 22A .0023. Certain business expenses of reservists,

performing artists, etc _____________________________ 23A .00 23B .0024. Health savings account deduction ____________________ 24A .00 24B .0025. Moving expenses (see instructions on page 16 ) _________ 25A .00 25B .0026. Deductible part of self-employment tax ________________ 26A .00 26B .0027. Self-employed, SEP, SIMPLE, and qualifi ed plans _______ 27A .00 27B .0028. Self-employed health insurance deduction _____________ 28A .00 28B .0029. Penalty on early withdrawal of savings ________________ 29A .00 29B .0030. Alimony paid ____________________________________ 30A .00 30B .0031. IRA deduction ____________________________________ 31A .00 31B .0032. Student loan interest deduction (see instructions) ________ 32A .00 32B .0033. Tuition and fees deduction (see instructions)____________ 33A .0034. Domestic production activities deduction _______________ 34A .0035. Other (see instructions) 35A .00 35B .0036. Add lines 22 through 35 ____________________________ 36A .00 36B .00

Section 3: Totals

37. Subtract line 36 from line 21 of Section 1. Carry amount from line 37B to Form IT-40PNR, line 1 ________ 37A .00 37B .00

Column AFederal Adjustments

Column BIndiana Adjustments

Schedule AForm IT-40PNR 2012

EnclosureSequence No. 01A

Page 2 of 2

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507

52100 26400


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Schedule D: Exemptions(Schedule E begins after line 7 below)


1. Number of exemptions claimed on your federal return x $1000 ____________________ 1 .00• If you did not claim an exemption on your federal return, enter “1” in the box above. • See instructions on page 28 if you did not fi le a federal return.

2. Claim an additional exemption for certain dependent children (see instructions).

Enter number you are eligible to claim x $1500: you MUST enclose Schedule IN-DEP __ 2 .003. Place “X” in box(es) below if, by December 31, 2012

You were age 65 or older and/or blind

Spouse was 65 or older and/or blind

Total number of boxes with Xs x $1000 _____________________________________ 3 .004. If age 65 or older, enter amount from Schedule A, line 37A $

If this amount is less than $40,000, place “X” in box(es) below if:

You were age 65 or older

Spouse was 65 or older

Total number of boxes with Xs x $500 ______________________________________ 4 .005. Add lines 1, 2, 3 and 4 ___________________________________________________________ 5 .006. Enter the number from Schedule A, Proration Section, line 21D ___________________________ 6 .7. Multiply line 5 by line 6. Enter here and on Form IT-40PNR, line 6 __________ Total Exemptions 7 .00

Schedule E: Other TaxesInstructions begin on page 30

1. Use tax on out-of-state purchases from line 4 of Sales/Use Tax Worksheet __________________ 1 .002. Household employment taxes. Enclose Schedule IN-H __________________________________ 2 .003. Recapture of Indiana’s CollegeChoice 529 credit. Enclose Schedule IN-529R ________________ 3 .004. Add lines 1 through 3. Enter here and on Form IT-40PNR, line 10. Total Other Taxes 4 .00


Schedules D & EForm IT-40PNR, State Form 54032(R3 / 9-12) 2012

Round all entries

��23712111594


4 4000

2 3000

7000

507

3549


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Schedule F: CreditsInstructions begin on page 30


1. Indiana state tax withheld: enclose W-2s, 1099s, WH-18s showing state tax withholding amounts 1 .002. Indiana county tax withheld: enclose W-2s, 1099s, WH-18s showing county tax withholding amts. 2 .003. Estimated tax paid for 2012: include any extension payment made with Form IT-9 ____________ 3 .004. Unifi ed tax credit for the elderly ____________________________________________________ 4 .005. Earned income credit: see instructions on page 31

Enter earned income credit fromSchedule IN-EIC, line A-3 _____________________________ Box A .00

Enter number from Schedule A, Proration Section, line 21D __________ Box B .Multiply Box A by Box B, enter total here ___________________________________________ 5 .00

6. Lake County residential income tax credit ____________________________________________ 6 .007. Economic development for a growing economy credit ___________________________________ 7 .008. Add lines 1 through 7. Enter total here and on Form IT-40PNR, line 12 __________ Total Credits 8 .00


Schedule FForm IT-40PNR, State Form 54033(R3 / 9-12) 2012

Round all entries

��23812111594


762

105

867


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Schedule G: Offset CreditsInstructions begin on page 43


1. Credit for local taxes paid outside Indiana ____________________________________________ 1 .002. County credit for the elderly: attach federal Schedule R _________________________________ 2 .003. Other Local Credits: See instructions (enclose additional sheets if necessary)

a. Enter credit name code no. 3a .00b. Enter credit name code no. 3b .00Important: Lines 1 through 3 cannot be greater than the county tax due on Form IT-40PNR, line 9 (see Combined Limitation instructions)

4. College credit: attach Schedule CC-40 ______________________________________________ 4 .005. Credit for taxes paid to other states: enclose other state’s return __________________________ 5 .006. Other Credits: See instructions (enclose additional sheets if necessary)

a. Enter credit name code no. 6a .00b. Enter credit name code no. 6b .00c. Enter credit name code no. 6c .00d. Enter credit name code no. 6d .00Important: Lines 4 through 6 added together cannot be greater than the state adjusted gross income tax due on Form IT-40PNR, line 8 (see Combined Limitations instructions)

7. Add lines 1 through 6. Enter total here and on line 13 of Form IT-40PNR Total Offset Credits 7 .00


Schedule GForm IT-40PNR, State Form 54034(R3 / 9-12) 2012

Round all entries

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777

777


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Schedule H Section 1: Residency Information(Complete Section 2: Additional Information on back)


List all state(s)and dates of your (and your spouse’s, if fi ling jointly) residency during 2012. Enter 2-letter state name (e.g. “IL” for Illinois) or the letters “OC” if you were a resident of a foreign country. Instructions begin on page 52.

Section 1: Residency Information

Schedule HForm IT-40PNRState Form 54035(R3 / 9-12)


Page 1 of 22012

IL 01 01 2012 06 01 2012 Yes X No

IN 06 02 2012 12 31 2012 Yes X No

Your information

1A 2012 2012 Yes No

1B 2012 2012 Yes No

1C 2012 2012 Yes No

1D 2012 2012 Yes No

Spouse’s information if married fi ling jointly

2A 2012 2012 Yes No

2B 2012 2012 Yes No

2C 2012 2012 Yes No

2D 2012 2012 Yes No

Turn over to complete Section 2

Example State of Residence

Date From(MM/DD)

Date To(MM/DD)

Did you fi le a tax return with the state/country? Place “X” in appropriate box.

(a)State ofResidence

(b)Date From(MM/DD)

(c)Date To(MM/DD)


(a)State ofResidence

(b)Date From(MM/DD)

(c)Date To(MM/DD)


��24012111594


IN 01 01 06 30

AL 07 01 12 31

AL 01 01 12 31


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Schedule H Section 2:Additional Required Information

Instructions begin on page 52.

1. Federal fi ling informationAre you fi ling a federal income tax return for 2012? Place “X” in appropriate box. Yes No

2. Extension of time to fi le 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.

3. Farm / Fishing incomePlace “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.

4. Date of deathIf any individual listed at the top of the IT-40PNR died during 2012, enter date of death (MM/DD).

Taxpayer’s date of death 2012 Spouse’s date of death 2012Authorization Sign Form IT-40PNR after reading the following statement.Under penalty of perjury, I have examined this return and all attachments and to the best of my knowledge and belief, it is true, com-plete 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 theSocial Security number(s) used on this return is correct.

5. Your daytime telephone number Your e-mail address

Schedule HForm IT-40PNRState Form 54035(R3 / 9-12)

2012

Section 2: Additional Information

I authorize the Department to discuss my return with my personal representative (see page 52 ).

Yes No If yes, complete the information below.

Personal Representative’s Name (please print)

Telephonenumber

Address

City

State Zip Code

Paid Preparer: Firm’s Name (or yours if self-employed)

IN-OPT on fi le with paid preparer if not fi ling electronically

PTIN

Address

City

State Zip Code


Page 2 of 2

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County Tax Schedule for Part-Yearand Full-Year Indiana Nonresidents


Lake County Residents: Turn to the Special Instructions for Lake County residents on page 56 if you and/or your spouse lived and/or worked in Lake County, Ind., on Jan. 1, 2012. If you determine that Lake County tax is due, fi nd your and/or spouse’s 4-digit code number (see page 57 ) and enter it here.

Your Lake County 4-digit number Spouse’s Lake County 4-digit number

SECTION 1: To be completed by those taxpayers who were residents of a county that had adopted a county income tax.

1. Enter the amount from IT-40PNR, line 7. Note: If both you andyour spouse lived in the same county on January 1 (or lived in thesame Lake County location on January 1), enter the entireamount from Form IT-40PNR, line 7 on line 1A only.See instructions on page 54 ___________________________ 1A .00 1B .00

2. If you claimed a non-Indiana locality earnings deduction on Schedule C, line 8, enter the amount here. If not, leave blank _ 2A .00 2B .00

3. Add lines 1 and 2 ____________________________________ 3A .00 3B .004. Enter the resident rate from the county tax chart on the back of

this schedule for the county where you lived on Jan. 1, 2012 __ 4A . 4B .5. Multiply line 3 by the rate on line 4 _______________________ 5A .00 5B .006. Add lines 5A and 5B. Enter the total here. Note: Perry County residents: If you live in Perry

County and worked in the Kentucky counties of Breckinridge, Hancock or Meade, you must complete lines 7 and 8. Otherwise, enter the total here and on line 9 below (see page 55 ). _____ 6 .00

7. Enter the amount of income that was taxed by any of the Kentucky counties listed on line 6 above 7 .008. Multiply line 7 by .0056 and enter total here ____________________________________________ 8 .009. Enter total of line 6 minus line 8. Continue with Section 2 below if you are married fi ling jointly and

you/spouse need to complete it. Otherwise, enter this amount on line 9 of Form IT-40PNR _______ 9 .00SECTION 2: To be completed by those taxpayers who, on Jan. 1, 2012, were residents of a county that had not adopted an Indiana county income tax, but worked in an Indiana county that had adopted a county income tax.

1. Enter your principal employment income. See page 55 for further Section 2 instructions _________________________ 1A .00 1B .00

2. Enter deductions. See page 56 for the complete list of allowable deductions and further instructions _______________ 2A .00 2B .00

3. Subtract line 2 from line 1 ______________________________ 3A .00 3B .004. Enter some or all of the exemptions from line 7 of

Schedule D (see instructions on page 56 ) ________________ 4A .00 4B .005. Subtract line 4 from line 3 ______________________________ 5A .00 5B .006. Enter the nonresident rate from the chart on the back of this

schedule for the county where you worked on Jan. 1, 2012 ____ 6A . 6B .7. Multiply the income on line 5 by the rate on line 6 ___________ 7A .00 7B .008. Enter total of 7A plus 7B; carry to Form IT-40PNR, line 9. (If you have an amount on Section 1,

line 9 above, combine that with the amount on line 8 and enter total on Form IT-40PNR, line 9) __ 8 .00

Column A - Yourself Column B - Spouse’s

Schedule CT-40PNRForm IT-40PNR, State Form 47906(R12 / 9-12)

Column A - Yourself Column B - Spouse’s


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26400

26400

3042

23358

00405

95

95


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Schedule IN-DEP: Additional Dependent Child Information(Instructions begin on page 24)

Name(s) shown on Form IT-40/IT-40PNR Your Social Security Number

Report on this schedule the fi rst and last name and Social Security number for each dependent child claimed as an additional exemp-tion on line 2 of Schedule 3 (from Form IT-40) or Schedule D (from Form IT-40PNR).

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.


Schedule IN-DEPForm IT-40/IT-40PNRState Form 54815 (R / 9-12)

2012

Child’sFirst Name

Child’sLast Name

Child’sSocial Security Number

��25612111594


NACHO CARR 300 00 3475

MIA CARR 300 00 3476


B1

Space Required for Barcode:

3.45” X 1.76”

B2


3.45” X 1.76”

B3


3.45” X 1.76”

Schedule IN-BAR: Barcode

Name(s) shown on Form IT-40, IT-40EZ, IT-40PNR or IT-40RNR Your Social Security Number

Designate the form with which Schedule IN-BAR is being fi led:

1. IT-40

2. IT-40EZ

3. IT-40PNR

4. IT-40RNR

2012 INDIANABarcode 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.

Schedule IN-BARState Form 54083(R3 / 9-12)

��24312111694




22222 a Employee’s social security number OMB No. 1545-0008

b Employer identification number (EIN)

c Employer’s name, address, and ZIP code

d Control number

e Employee’s first name and initial Last name Suff.

f Employee’s address and ZIP code

1 Wages, tips, other compensation 2 Federal income tax withheld

3 Social security wages 4 Social security tax withheld

5 Medicare wages and tips 6 Medicare tax withheld

7 Social security tips 8 Allocated tips

9 10 Dependent care benefits

11 Nonqualified plans 12a Co d e

12bCo d e

12cCo d e

12dCo d e

13 Statutory employee

Retirement plan

Third-party sick pay

14 Other

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

Form W-2 Wage and Tax Statement 2012 Department of the Treasury—Internal Revenue Service

Copy 1—For State, City, or Local Tax Department

400-00-4051

35-1234568 26400 2905

NEWCO COMMUNICATIONS1449 W 16TH STINDIANAPOLIS IN 46202

26400

26400

TEST A CARR5400 OAKWOOD STBIRMINGHAM AL 35228

IN 003666950002 26400 762 12980 43 49

IN 003666950002 11000 47 29





d Control number









12bCo d e

12cCo d e

12dCo d e


Retirement plan


14 Other




400-00-4051

35-1234568

NEWCO COMMUNICATIONS1449 W 16TH STINDIANAPOLIS IN 46202


IN 003666950002 2420 15 CASS





d Control number









12bCo d e

12cCo d e

12dCo d e


Retirement plan


14 Other




400-00-4051

63-9817654 4000 436

MNR RADIO321 TIN VALLEY CIRBIRMINGHAM AL 35235


AL 639817654 4000 375





d Control number









12bCo d e

12cCo d e

12dCo d e


Retirement plan


14 Other




400-00-4052

63-1239871 21400 3577

CARS R US100 S BIRMINGHAM WAYBIRMINGHAM AL 35228

21400

21400

MERCEDES X CARR5400 OAKWOOD STBIRMINGHAM AL 35228

AL 631239871 21400 1782


indiana 2012 barcode test #14 2012...

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