Fillable Form 2019: 502B Dependents' Information (Attach To Form (Comptroller of Maryland)

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Form 2019: 502B Dependents' Information (Attach To Form (Comptroller of Maryland)

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

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Completed 21 July 2020

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