Fillable Form 111111111111111111: 502B 2019 I llllll 111111111111111 (Attach (Comptroller of Maryland)

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Form 111111111111111111: 502B 2019 I llllll 111111111111111 (Attach (Comptroller of Maryland)

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  • 36 check-boxes
  • 85 other fields

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File type: PDF

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BROWSE COMPTROLLER OF MARYLAND (MD) FORMS

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MARYLAND
FORM
502B
2019
Dependents' Information
(Attach to Form 502, 505
or 515.)
COM/RAD-026
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I llllll
111111111111111
111111111111111
111111111111111111
19502B049
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Print Using Blue or Black Ink Only
Your Social Security Number Spouse's Social Security Number
Your First Name MI
Your Last Name
Spouse's First Name MI
Spouse's Last Name
Summary
1. Enter the total number checked below for Regular dependents (4) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Enter the total number checked below for dependents 65 or over (5) . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Total dependent exemptions (Add lines 1 and 2 and enter the total here and on line (C) of the
1.
2.
Exemptions area of Form 502, 505 or 515.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.
Dependents (If a dependent listed below is age 65 or over, check both 4 and 5.)
1.
First Name MI Last Name
Check here if this dependent does
2.
Social Security Number Relationship
3.
Regular
4.
65 or over
5.
not have health care coverage
DOB (MM/DD/YYYY)
1.
First Name MI Last Name
Check here
if this dependent does
2.
Social Security Number Relationship
3.
Regular
4.
65 or over
5.
not have health care coverage
DOB (MM/DD/YYYY)
1.
First Name MI Last Name
Check here if this dependent does
2.
Social Security Number Relationship
3.
Regular
4.
65 or over
5.
not have health care coverage
DOB (MM/DD/YYYY)
1.
First Name MI Last Name
Check here
if this dependent does
2.
Social Security Number Relationship
3.
Regular
4.
65 or over
5.
not have health care coverage
DOB (MM/DD/YYYY)
1.
First Name MI Last Name
Check here if this dependent does
2.
Social Security Number Relationship
3.
Regular
4.
65 or over
5.
not have health care coverage
DOB (MM/DD/YYYY)
1.
First Name MI Last Name
Check here
if this dependent does
2.
Social Security Number Relationship
3.
Regular
4.
65 or over
5.
not have health care coverage
DOB (MM/DD/YYYY)
MARYLAND
FORM
502B
2019
Dependents' Information
(Attach to Form 502, 505
or 515.)
COM/RAD-026
■
I llllll
111111111111111
111111111111111
111111111111111111
19502B149
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Page 2
NAME SSN
First Name MI Last Name
1.
Check here if this dependent does
Social Security Number Relationship Regular 65 or over
not have health care coverage
2. 3. 4. 5.
DOB (MM/DD/YYYY)
First Name MI Last Name
1.
Check here if this dependent does
Social Security Number Relationship Regular 65 or over
not have health care coverage
2. 3. 4. 5.
DOB (MM/DD/YYYY)
First Name MI Last Name
1.
Check here if this dependent does
Social Security Number Relationship Regular 65 or over
not have health care coverage
2. 3. 4. 5.
DOB (MM/DD/YYYY)
First Name MI Last Name
1.
Check here if this dependent does
Social Security Number Relationship Regular 65 or over
not have health care coverage
2. 3. 4. 5.
DOB (MM/DD/YYYY)
First Name MI Last Name
1.
Check here if this dependent does
Social Security Number Relationship Regular 65 or over
not have health care coverage
2. 3. 4. 5.
DOB (MM/DD/YYYY)
First Name MI Last Name
1.
Check here if this dependent does
Social Security Number Relationship Regular 65 or over
not have health care coverage
2. 3. 4. 5.
DOB (MM/DD/YYYY)
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Form 111111111111111111: 502B 2019 I llllll 111111111111111 (Attach (Comptroller of Maryland)

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Completed 20 July 2020

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