Organ Donor
Program
Fund
X
4. Mark your filing status box below and enter the appropriate exemption amount on Line 4.
4 00
5.
Tax from federal return (Do not Enter this amount on Line 5 or $5,000, whichever is less.
enter federal income tax withheld.) — If married filing combined, enter this amount on Line 5
or $10,000, whichever is less.
5 + 00
6. Missouri standard deduction or itemized deductions.
Single or Married Filing Separate— $6,300; Head of
Household — $9,250; Married Filing a Combined Return or Qualifying Widow(er) — $12,600
. If you are age 65 or
older, blind, or claimed as a dependent, see your federal return or page 7. If you are itemizing, see back of form. 6 + 00
7.
Number of dependents you claimed on your Federal Form 1040 OR 1040A, Line 6c.
Check box if claiming a stillborn child; see instructions on Page 7...........................................................
x $1,200 =
7 + 00
8. Long-term care insurance deduction ...................................................................................................................... 8 + 00
9. Total Deductions — Add Lines 4 through 8. ...........................................................................................................
9 = 00
12. Missouri tax withheld from your Forms W-2 and Forms 1099. Attach copies of Forms W-2 and Forms 1099. .... 12 00
13. Any Missouri estimated tax payments made for 2015 (include overpayment from 2014 applied to 2015) ............ 13 00
14. Total Payments — Add Lines 12 and 13. ...............................................................................................................
14 00
15. If Line 14 (Total Payments) is more than Line 11 (Total Tax), enter the difference (amount of overpayment)
here. (If Line 14 is less than Line 11, skip to Line 20.) ........................................................................................... 15 00
16. Amount from Line 15 that you want applied to your 2016 estimated tax ............................................................. 16 00
10. Missouri Taxable Income — Subtract Line 9 from Line 3. ...................................................................................... 10 00
11. Tax — Use the tax chart on the back of this form to figure the tax. .......................................................................
11 00
1. Federal adjusted gross income from your 2015 federal return. (See page 6 of the instructions.). ................................. 1 00
2. Any state income tax refund included in your 2015 federal adjusted gross income. ............................................ 2 – 00
3. Total Missouri adjusted gross income — Subtract Line 2 from Line 1. .................................................................
3 = 00
INCOMEDEDUCTIONS
TAX
REFUND
AMOUNT DUE
I authorize the Director of Revenue or delegate to discuss my return and
attachments with the preparer or any member of the preparer’s firm.
YES NO
SIGNATURE
A. Single — $2,100 (See Box B before checking.)
B. Claimed as a dependent on another person’s federal
tax return — $0.00
C. Married filing joint federal & combined Missouri — $4,200
Check which spouse had income: Yourself Spouse
PREPARER’S PHONEE-MAIL ADDRESS
SIGNATURE DATE PREPARER’S SIGNATURE FEIN, SSN, OR PTIN
SPOUSE’S SIGNATURE (If filing combined, BOTH must sign) DAYTIME TELEPHONE PREPARER’S ADDRESS AND ZIP CODE DATE
For Privacy Notice, see instructions.
IN CARE OF NAME (ATTORNEY, EXECUTOR, PERSONAL REP., ETC.)
PRESENT ADDRESS (INCLUDE APARTMENT NO. OR RURAL ROUTE) COUNTY OF RESIDENCE
CITY, TOWN, OR POST OFFICE STATE ZIP CODE
AGE 65 OR OLDER BLIND 100% DISABLED NON-OBLIGATED SPOUSE
YOURSELF YOURSELF YOURSELF YOURSELF
SPOUSE SPOUSE SPOUSE SPOUSE
PLEASE CHECK THE APPROPRIATE BOXES THAT APPLY TO YOURSELF OR YOUR SPOUSE.
MISSOURI DEPARTMENT OF REVENUE 2015 FORM MO-1040A
INDIVIDUAL INCOME TAX RETURN
SINGLE/MARRIED
(
ONE INCOME
)
SOCIAL SECURITY NUMBER SPOUSE’S SOCIAL SECURITY NUMBER
NAME (LAST) (FIRST) M.I. JR, SR
SPOUSE’S (LAST) (FIRST) M.I. JR, SR
VENDOR CODE
006
D. Married filing separate — $2,100
E. Married filing separate (spouse
NOT filing) — $4,200
F. Head of household — $3,500
G. Qualifying widow(er) with
dependent child — $3,500
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief it is true, correct, and complete. Declaration of
preparer (other than taxpayer) is based on all information of which he or she has any knowledge. As provided in Chapter 143, RSMo, a penalty of 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 for any tax exemption, credit or abatement if I employ such aliens.
19. REFUND -
Subtract Lines 16, 17, and 18 from Line 15 and enter here. This is your refund.
Sign below and mail to
:
Department of Revenue, P.O. Box 3222, Jefferson City, MO 65105-3222. ...................................................... 19 00
20. AMOUNT DUE - If Line 14 is less than Line 11, enter the difference here. You have an amount due. Sign below and
mail to: Department of Revenue, P.O. Box 3370, Jefferson City, MO 65105-3370. See instructions for Line 20. ...... 20 00
If you pay by check, you authorize the Department of Revenue to process the check electronically. Any check returned unpaid may be presented again electronically.
If you would like your refund deposited directly to your checking or savings account, complete boxes a, b, and c below.
a. Routing Number b. Account Number c.
Checking Savings
DECEASED
IN 2015
17.
Enter the amount of your
donation in the trust fund
boxes to the right. See
instructions for fund codes...17.
00 00 00 00 00 00 00 00 00 00 00
Workers
Additional
Fund Code
(See Instr.)
______|______
Children’s
Trust
Fund
Veterans
Trust
Fund
Missouri
National Guard
Trust Fund
Workers’
Memorial
Fund
Elderly Home
Delivered Meals
Trust Fund
Childhood Lead
Testing
Fund
General
Revenue
LEAD
Missouri Military
Family Relief
Fund
General
Revenue
Fund
Additional
Fund Code
(See Instr.)
______|______
(__ __ __) __ __ __ - __ __ __ __
(__ __ __) __ __ __ - __ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
MO-1040A 2-D (Revised 12-2015)
18.
Amount from Line 15 to be deposited into a Missouri 529 College Savings Plan (MOST) account. Enter amount from Line E of Form 5632.
18 00
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