US 1040
Main Information Sheet
2012
Taxpayer
PRINTED 10/12/2013
MARY
SSN
Birth
Death
Day Phone
Evening
Cell or Fax
BERINGER
1040 Wilson Lane
WORCESTER MA 01601
Spouse
031-01-6074
12/26/1953
704-555-1234
PIN
Email
Taxpayer Occupation
Filing Status
Corey
Asia
Angie
Sales Manager
HEAD OF HOUSEHOLD
JOHNSON
JOHNSON
JESSE
Preparer ID:
Preparer:
Spouse Occupation
10/30/1996 033-01-6074 SON
02/10/1995 032-01-6074 DAUGHTER
05/20/1934 034-01-6074 PARENT
Preparation Fee:
12
12
12
1
1
3
Date:
PETER H VILES
Time in return
Recap of 2012 Income Tax Return
Earned Income ..........
Federal AGI ..............
Taxable Income ..........
EIC ......................
State ..................
Tax ....................
Withholding ..........
Refund/Due............
State ..................
Tax ....................
Withholding ..........
Refund/Due............
35,689.
49,884.
25,984.
Federal Tax ..............
Withholding ..............
Refund/(Due)..............
Tax Bracket ..............
2,276.
1,526.
(750.)
15.0 %
MA
1,064.
860.
(204.)
Bank Product Information
Check
Qualifying refund .............................................
Fees ...........................................................
Net refund ......................................................
Federal disbursement...........................................
State disbursement ............................................
Check one .....................................................
Oc 2012 CCH Small Firm Services. All rights reserved.
US104001
Direct Deposit
Debit Card
min.
2012
Department of the Treasury
Form 1040-V
Internal Revenue Service
What Is Form 1040-V
How To Prepare Your Payment
It is a statement you send with your check or money
order for any balance due on the "Amount you owe" line
of your 2012 Form 1040, Form 1040A, or Form 1040EZ.
|
Make your check or money order payable to "United
States Treasury." Do not send cash.
| Make sure your name and address appear on your
check or money order.
| Enter your daytime phone number and your SSN on
your check or money order. If you are filing a joint return,
enter the SSN shown first on your return. Also enter
"2012 Form 1040," "2012 Form 1040A," or "2012 Form
1040EZ," whichever is appropriate.
| To help us process your payment, enter the amount on
the right side of your check like this: $ XXX.XX. Do not
use dashes or lines (for example, do not enter "$ XXX-"
or "$ XXX xx/100").
You can also pay your taxes online or by phone either by a
TIP direct transfer from your bank account or by credit or debit
card. Paying online or by phone is convenient and secure
and helps make sure we get your payments on time. For
more information, go to www.irs.gov/e-pay.
How To Fill In Form 1040-V
Line 1. Enter your social security number (SSN). If you are
filing a joint return, enter the SSN shown first on your
return.
Line 2. If you are filing a joint return, enter the SSN shown
second on your return.
Line 3. Enter the amount you are paying by check or
money order.
Line 4. Enter your name(s) and address exactly as shown
on your return. Please print clearly.
How To Send In Your 2012 Tax Return,
Payment, and Form 1040-V
| Detach Form 1040-V along the dotted line.
| Do not staple or otherwise attach your payment or Form
1040-V to your return or to each other. Instead, just put
them loose in the envelope.
| Mail your 2012 tax return, payment, and Form 1040-V to
the address shown on page 2 that applies to you.
US1040V1
Form
BCA
2012
|Use this voucher when making a payment with Form 1040
|Do not staple this voucher or your payment to Form 1040
|Make your check or money order payable to the "United States Treasury"
|Write your Social Security Number (SSN) on your check or money order
031-01-6074
MARY BERINGER
1040 Wilson Lane
WORCESTER MA 01601
j
j
Department of the Treasury
Internal Revenue Service
Detach Here and Mail With Your Payment and Return
1040-V (2012)
Form 1040-V Payment Voucher
Amount you are
paying by check
or money order
Dollars
j
1045
PO Box 37008
Hartford CT 06176-0008
031016074 ZW BERI 30 0 201212 610
Cents
750.
Form
Department of the Treasury - Internal Revenue Service
(99)
U.S. Individual Income Tax Return
For the year Jan. 1-Dec. 31, 2012, or other tax year beginning
Your first name and initial
2012
OMB No. 1545-0074
,2012, ending
IRS Use Only-Do not write or staple in this space.
See separate instructions.
Your social security number
,20
Last name
MARY BERINGER
If a joint return, spouse's first name and initial
031-01-6074
Last name
Spouse's social security no.
Home address (number and street). If you have a P.O. box, see instructions.
Apt. no.
1040 Wilson Lane
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions).
WORCESTER MA 01601
Foreign country name
Foreign province/county
Foreign postal code
k
l
1040
Make sure the SSN(s) above
and on line 6c are correct.
Presidential Election Campaign
Check here if you, or your spouse if filing
jointly, want $3 to go to this fund. Checking a box below will not change your tax
or refund.
You
Spouse
Single
4 X Head of household (with qualifying person). (See instructions.)
Filing Status
Married filing jointly (even if only one had income)
If the qualifying person is a child but not your dependent, enter
Married filing separately. Enter spouse's SSN above
this child's name here.j
Check only
one box.
and full name here. j
5
Qualifying widow(er) with dependent child
X Yourself. If someone can claim you as a dependent, do not check box 6a ................ Boxes checked on
Exemptions
6a
j
1
b
Spouse .................................................................................. 6a and 6b
No. of children
/
(3)
(4)
if
child
under
Dependent's
V
If more than
c
Dependents:
(2) Dependent's
under age 17 quali- on 6c who:
relationship to
fying for child tax
2
four depen- (1) First name
Last name
social security no.
you
lived with you
credit (see instr.)
did not live with
Corey JOHNSON
033-01-6074SON
X
dents, see
you due to divorce
or separation
Asia JOHNSON
032-01-6074DAUGHTER
0
instr. and
(see instr.)
Dependents
on 6c
Angie JESSE
034-01-6074PARENT
1
check
not entered above
here j
Add numbers
4
d Total number of exemptions claimed ............................................................................ on lines abovej
Income
7 Wages, salaries, tips, etc. Attach Form(s) W-2
35,689.
7
8a
Taxable
interest.
Attach
Schedule
B
if
required
..........................................
8a
Attach
Form(s) W-2 here.
b Tax-exempt interest. Do not include on line 8a .......... 8b
Also attach Forms
9a Ordinary dividends. Attach Schedule B if required ........................................ 9a
W-2G and
b Qualified dividends ...................................... 9b
1099-R if tax
was withheld.
10 Taxable refunds, credits, or offsets of state and local income taxes ........................ 10
11 Alimony received .......................................................................... 11
12 Business income or (loss). Attach Schedule C or C-EZ .................................... 12
13 Capital gain or (loss). Attach Schedule D if required. If not required, check here j
13
If you did not
get a W-2,
14 Other gains or (losses). Attach Form 4797 ................................................ 14
see instructions.
15a IRA distributions .......... 15a
b Taxable amount .......... 15b
16a Pensions and annuities .... 16a
b Taxable amount .......... 16b
17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E .... 17
18 Farm income or (loss). Attach Schedule F ................................................ 18
Enclose, but do
19 Unemployment compensation ............................................................ 19
not attach, any
24,750. b Taxable amount .......... 20b
14,195.
payment. Also, LSE 20a Social security benefits .. 20a
please use
21 Other income. List type and amount (see instr.)
21
Form 1040-V.
49,884.
22 Combine the amounts in the far right column for lines 7 through 21.This is your total income
j 22
23 Educator expenses ........................................ 23
Adjusted
24 Certain business expenses of reservists, performing artists,
Gross
and fee-basis gov. officials. Attach Form 2106 or 2106-EZ .. 24
Income
25 Health savings account deduction. Attach Form 8889 ...... 25
26 Moving expenses. Attach Form 3903 ...................... 26
27 Deductible part of self-employment tax. Attach Schedule SE 27
28 Self-employed SEP, SIMPLE, and qualified plans
........ 28
29 Self-employed health insurance deduction ................ 29
30 Penalty on early withdrawal of savings .................... 30
31a Alimony paid b Recipient's SSN j
31a
32 IRA deduction
.......................................... 32
33 Student loan interest deduction
.......................... 33
34 Tuition and fees. Attach Form 8917 ........................ 34
35 Domestic production activities deduction. Attach Form 8903 35
36 Add lines 23 through 35 .................................................................. 36
49,884.
37 Subtract line 36 from line 22. This is your adjusted gross income .................... j 37
BCA For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions.
US1040$1
Form 1040 (2012)
1
2
3
.
.
MARY BERINGER
Form 1040 (2012)
Tax and
Credits
031-01-6074
38 Amount from line 37 (adjusted gross income) ..............................................
39a Check
You were born before Jan. 2, 1948,
Blind.
j Total boxes
if:
Spouse was born before Jan. 2, 1948,
Blind.
checked j 39a
j 39b
b If your spouse itemizes on a separate return or you were a dual-status alien, check here
40 Itemized deductions (from Schedule A) or your standard deduction (see left margin) ......
41 Subtract line 40 from line 38 ..............................................................
42 Exemptions. Multiply $3,800 by the number on line 6d ....................................
43 Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter -0- ......
44 Tax (see instructions). Check if any tax is from:
a Form(s) 8814 b Form 4972 c
962 election
.
45 Alternative minimum tax (see instructions). Attach Form 6251 ............................
46 Add lines 44 and 45 ................................................................... j
47 Foreign tax credit. Attach Form 1116 if required ............ 47
48 Credit for child and dependent care expenses. Attach Form 2441
...... 48
49 Education credits from Form 8863, line 19 .................. 49
50 Retirement savings contributions credit. Attach Form 8880 .. 50
1,000.
51 Child tax credit. Attach Schedule 8812, if required .......... 51
52 Residential energy credits. Attach Form 5695
52
53 Other credits from Form:
a
3800 b
8801 c
53
54 Add lines 47 through 53. These are your total credits ......................................
55 Subtract line 54 from line 46. If line 54 is more than line 46, enter -0- .................. j
Page 2
38
49,884.
40
41
42
43
44
45
46
8,700.
41,184.
15,200.
25,984.
3,276.
j
Standard
Deduction
for| People who
check any
box on line
39a or 39b or
who can be
claimed as a
dependent,
see
instructions.
| All others:
Single or
Married filing
separately,
$5,950
Married filing
jointly or
Qualifying
widow(er),
$11,900
Head of
household,
$8,700
Other
Taxes
3,276.
1,000.
2,276.
54
55
56
57
58
59a
59b
60
61
56 Self-employment tax. Attach Schedule SE ................................................
57 Unreported social security and Medicare tax from Form: a
4137
b
8919 ....
58 Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required ..
59a Household employment taxes from Schedule H ............................................
b First-time homebuyer credit repayment. Attach Form 5405 if required ......................
60 Other taxes. Enter code(s) from instructions
61 Add lines 55 through 60. This is your total tax ........................................ j
1,526.
FORM
62 Federal income tax withheld from Forms W-2 and 1099 .... 62
Payments
63 2012 estimated tax payments and amount applied from 2011 return
.... 63
If you have a
NO
64a Earned income credit (EIC) ..............................
64a
qualifying child,
combat
b Nontaxable
........
64b
attach Schedule
pay election
EIC.
65 Additional child tax credit. Attach Form 8812................ 65
66 American opportunity credit from Form 8863, line 8.......... 66
67 Reserved ................................................
........ 67
68 Amount paid with request for extension to file
............ 68
69 Excess social security and tier 1 RRTA tax withheld ........ 69
70 Credit for federal tax on fuels. Attach Form 4136
70
Re71 Credits from Form: a 2439 b served c 8801 d 8885
71
72 Add lines 62, 63, 64a, and 65 through 71. These are your total payments .............. j 72
73 If line 72 is more than line 61, subtract line 61 from line 72. This is the amount you overpaid 73
Refund
74a Amount of line 73 you want refunded to you. If Form 8888 is attached, check here j
74a
Routing
Savings
j
b number
j c Type: Checking
Account
Direct deposit? j
d number
See instructions
75 Amount of line 73 you want applied to your 2013 estimated tax j 75
76 Amount you owe. Subtract line 72 from line 61. For details on how to pay, see inst. .... j 76
Amount
You Owe
77 Estimated tax penalty (see instructions) .................... 77
Yes. Complete below.
Third Party Do you want to allow another person to discuss this return with the IRS (see instructions)?
j
BCA
j
Your signature
k
l
750.
X
No
Date
j
Your occupation
Daytime phone number
Sales Manager
Spouse's signature.If a joint return, both must sign.
Print/Type preparer's name
Paid
Preparer's
Use Only
1,526.
Designee's
Personal identification
Phone
number (PIN)
name
no.
Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and
belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Designee
Sign
Here
Joint return?
See instr.
Keep a copy
for your
records.
2,276.
1099
Date
Preparer's signature
PETER H VILES
PETER H VILES
Firm's name
j AARP Foundation TaxAide
Firm's address
j
US1040$2
704-555-1234
Spouse's occupation
Date
If the IRS sent you an Identity
Protection PIN,
enter it here
(see inst.)
Check
if
PTIN
self-employed
Firm's EIN j
Phone no.
Form
1040 (2012)
US
Name:
1040, 1040A, 1040EZ, 1040NR Income Worksheet
MARY BERINGER
2012
SSN:
031-01-6074
Interest. List all interest on Schedule B, regardless of the amount.
Unemployment and/or state tax refund. Fill out 1099G worksheet
Taxpayer
Spouse
Total
Social Security/Railroad Tier 1 Benefits
Taxpayer
Spouse
Total
Social Security received this year ................................................
Railroad tier 1 received this year ................................................
Total ..........................................................................
Medicare to Schedule A ..........................................................
Federal tax withheld ............................................................
24,750.
Additional Earned Income
Scholarship income - no W2 ......................................................
Household employee income - no W2 ............................................
24,750.
24,750.
500.
Married Filing Separately
If the filing status is married filing separately and the taxpayer and spouse lived together at any
time during the year, up to 85% of social security and railroad benefits received are taxable. See Main
Information Sheet, filing status 3 ..............................................................................................
All others
Modified adjusted gross income for this computation consists of AGI (without social security or railroad benefits) + Form 8815,
35,689.
line 14, + Form 8839, line 30 + Form 2555 (EZ) exclusions + student loan interest adjustment
+ tax-exempt interest:
and excluded income from American Samoa (Form 4563) or
12,375. ................................
Puerto Rico:
+ 50% of the benefits received:
48,064.
If the modified AGI is less than $25,001 ($32,001 married filing jointly), none of the Social Security and RR Benefits are taxable
....
If the modified AGI is between $25,000 and $34,000 ($32,000 and $44,000 married filing joIntly), 50% of the benefits
received is taxable............................................................................................................
If the modified AGI is greater than $34,000 ($44,000 married filing jointly):
85% of the social security and railroad benefits received is taxable ..........................A
48,064.
Modified AGI ....................
34,000.
$34,000 ($44,000)................
14,064. X 85%=
11,954.
Subtract..........................
21,038.
Minimum 50% of the benefits received or $4,500 ($6,000 married filing
4,500.
jointly) .................................................................
16,454.
Add........................................................................................ B
Taxable social security and railroad retirement tier 1. Minimum of A or B ................................................
16,454.
Lump Sum Payment of Social Security and Railroad Tier 1 Benefits
Taxpayer
Spouse
8,250.
Gross amount received attributable to 2012 ......................................
Using the above modified AGI, this is the taxable amount of the 2011 benefit ..................................................
Amounts taxable from previous years..........................................................................................
Taxable benefits using the lump-sum election method ....................................................................
Oc 2012 CCH Small Firm Services. All rights reserved.
USW10401
Total
8,250.
7,013.
7,182.
14,195.
US
Name:
Child Tax Credit, Federal Extension Payment, and Carryovers Worksheet
2012
MARY BERINGER
SSN: 031-01-6074
Child Tax Credit (CTC)
1 $1,000 X 1 qualifying children ..................................................
2 Modified AGI is AGI plus excluded income from Forms 2555 (EZ) and 4563,
and excluded income from Puerto Rico ..............................................
3 Modified AGI limitation $110,000 married filing jointly; $55,000 married filing
separately; all others $75,000 ........................................................
4 Subtract line 3 from line 2. If -0-, go to line 7 ........................................
5 Round up to next $1,000 ............................................................
6 Multiply line 5 by 5% ................................................................
7 Maximum child tax credit. Subtract line 6 from line 1.
You cannot take the credit if this amount is -0- ......................................
8 Amount from Form 1040, line 46, Form 1040A, line 28, or Form 1040NR, line 43........
9 Credits for foreign tax, dependent care, elderly, education, retirement savings,
adoption, mortgage interest, DC first-time homebuyers and residential energy .........
1,000.
49,884.
75,000.
1,000.
3,276.
CTC Worksheet for Forms 8396, Mortgage Interest Credit, Form 8839, Adoption Credit,
Form 8859, DC First-time Homebuyers Credit, and Form 5695, Residential Energy Credits
1 Foreign tax credit + dependent care credit + elderly credit + education credit +
retirement savings credit .....................................................
2 Amount from line 7 above ....................................................
3 Social security or RR tier 1 + Medicare ........................................
4 Form 1040, line 27 + line 59; or Form 1040NR, line 54 + uncollected social
security and Medicare taxes listed on W2 ......................................
5 Add lines 3 and 4 ............................................................
6 Earned income credit and excess FICA/RRTA ..................................
7 Subtract line 6 from line 5 ....................................................
8 Maximum child tax credit, line 7 above, minus the larger of line 7 of this
worksheet or Form 8812, line 6. This is the child tax credit for the purpose of
figuring Forms 5695, 8396, 8839 and 8859. Use this amount in place of the child
tax credit amount asked for on these forms ....................................
9 Total of adoption credit, mortgage interest credit, DC first-time homebuyer
credit, and residential energy credits as refigured.................................
10 Add lines 1 and 9 ..............................................................
10 Subtract line 9 from line 8 ........................................................................................
11 Child tax credit
................................................................................................
Amount paid with Federal extension (Form 4868 or 2350) ............................................................
Carryovers from 2012 to 2013
3,276.
1,000.
1 Section 179 expense disallowed, Form 4562, accumulative total......................................................
2 Net operating loss from 2012 only, Form 1045 ......................................................................
Amt. carried forward from 2011. Listed on Form 1040, line 21, or Form 1040NR, line 21
3 2012 charitable contributions. Organization limit:
Cash or other property
Capital Gain
50%
30%
30%
20%
4 Investment interest expense, Form 4952, accumulative total..........................................................
5 Foreign tax credit from 2012 only, Form 1116. Enter amount carried back, if any........
6 Mortgage interest credit, Form 8396
2010
2011
2012
7
8
9
10
DC first-time homebuyer credit, Form 8859..........................................................................
Prior year minimum tax credit, Form 8801, cumulative total ........................................................
AMT limited qualified electric vehicle credit from 2012 only ..........................................................
Nonrecaptured net section 1231 losses
2008
2009
2010
2011
2012
Oc 2012 CCH Small Firm Services. All rights reserved.
USW10403
031-01-6074
W-2 DETAIL REPORT - 2012
Employer
EIN
------------------------ ----------
TP|SP
-----
Mount Peace Associates I 11-0123456
X
Gross
Wages
-------
Federal
With.
-------
FICA
-------
35689
----35689
1026
---1026
1499
---1499
Medicare
-------
517
--517
St
--
MA
State
Wages
-------
State
With.
-------
35689
----35689
860
--860
Locality
---------
Local
With.
-------
2012 Form 1 MA1200111045
Massachusetts Resident Income Tax Return
FOR FULL YEAR RESIDENTS ONLY
For the year January 1 - December 31, 2012 or other taxable
Yr. beginning
Ending
MARY
BERINGER
1040 WILSON LANE
031-01-6074
WORCESTER
MA 01601
Apt. no.
State Election Campaign Fund:
j
j
j
j
j
j
Fill in if veteran of U.S. armed forces who served in Operation Enduring Freedom, Iraqi Freedom or Noble Eagle
Taxpayer deceased
Fill in if under age 18
1. Filing status (select one only):j
X
$1 You
$1 Spouse TOTAL j
You j
Spouse
You
Spouse
You j
Spouse
Name/address changed since 2011
Fill in if noncustodial parent
Fill in if filing Schedule TDS
Single
Married filing joint
Married filing separate return
Head of household j
You are a custodial parent who has released claim to exemption for child(ren)
2. Exemptions
a. Personal exemptions
2a
3
b. Number of dependents. (Do not include yourself or your spouse.)
Enter number j
x $1,000= 2b
c. Age 65 or over before 2013
You +
Spouse =
j
x $700= 2c
d. Blindness
You +
Spouse =
j
x $2,200= 2d
e. 1. Medical/dental j
2. Adoption j
1 + 2 = 2e
f. Total exemptions. Add lines 2a through 2e. Enter here and on line 18
j 2f
3. Wages, salaries, tips
j 3
4. Taxable pensions and annuities
j 4
5. Mass. bank interest:a. j
-b.exemption
= 5
6. Business/profession or farm income or loss
j 6
7. Rental, royalty and REMIC, partnership, S corp., trust income/loss
j 7
8a. Unemployment
j 8a
8b. Mass. lottery winnings
j 8b
9. Other income from Schedule X, line 5
j 9
10. TOTAL 5.25% INCOME
10
SIGN HERE. Under penalties of perjury, I declare that to the best of my knowledge and belief this return and enclosures are true, correct and complete.
Your signature
Date
Spouse's signature
Date
May the Dept. of Revenue discuss this return with the preparer shown here?
I do not want preparer to file my return electronically
Print paid preparer's name
PETER
H VILES
j
j
9800
35689
35689
Yes
(this may delay your refund)
Date
Check if self-employed
10122013
Paid preparer's signature
6800
3000
Paid preparer's SSN
j
Paid preparer's phone
Paid preparer's EIN
j
PETER H VILES
PRIVACY ACT NOTICE AVAILABLE UPON REQUEST
10/12/2013 11:38:11
MA1$$$$1
2012 Form 1, pg. 2 MA1200121045
Massachusetts Resident Income Tax Return
031-01-6074
11a.
11b.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
Amount paid to Soc. Sec. Medicare, R.R., U.S. or Mass. Retirement
j 11a
Amount your spouse paid to Soc. Sec., Medicare, R.R., U.S. or Mass. Retirement
j 11b
Child under age 13, or disabled dependent/spouse care expenses
j 12
Number of dependent member(s) of household under age 12, or dependents age 65 or over (not you or your spouse) as of
12/31/12, or disabled dependent(s)
Not more than two. a.j 1
x $3,600 = j 13
.
Rental deduction. a. j
. 2 = j 14
Other deductions from Schedule Y, line 17
j 15
Total deductions. Add lines 11 through 15
j 16
5.25% INCOME AFTER DEDUCTIONS. Subtract line 16 from line 10. Not less than ``0"
17
Exemption amount
18
5.25% INCOME AFTER EXEMPTIONS. Subtract line 18 from line 17. Not less than ``0"
19
INTEREST AND DIVIDEND INCOME
j 20
TOTAL TAXABLE 5.25% INCOME. Add lines 19 and 20
21
TAX ON 5.25% INCOME. Note: If choosing the optional 5.85% tax rate, fill in and multiply line 21 and the
amount in Sch. D, line 21 by .0585 j
22
12% INCOME. Not less than "0."
a. j
x .12 = 23
TAX ON LONG-TERM CAP. GAINS. Not less than ``0". Fill in if filing Sch. D-IS j
j 24
Fill in if any excess exemptions were used in calculating lines 20, 23 or 24
j
Credit recapture amount
j
BC
EOA
LIH
HR
j 25
Additional tax on installment sale
j 26
If you qualify for No Tax Status, fill in and enter "0" on line 28
j
TOTAL INCOME TAX. Add lines 22 through 26
28
Limited Income Credit
j 29
Other credits from Schedule Z, line 13
j 30
31
INCOME TAX AFTER CREDITS. Subtract the total of lines 29 and 30 from line 28. Not less than "0"
BE SURE TO INCLUDE THIS PAGE WITH FORM 1, PAGE 1
10/12/2013 11:38:11
MA1$$$$2
2000
3600
5600
30089
9800
20289
20289
1064
1064
1064
2012 Form 1, pg. 3 MA1200131045
Massachusetts Resident Income Tax Return
031-01-6074
32. Voluntary Contributions
a. Endangered Wildlife Conservation
j 32a
b. Organ Transplant Fund
j 32b
c. Massachusetts AIDS Fund
j 32c
d. Massachusetts U.S. Olympic Fund
j 32d
e. Massachusetts Military Family Relief Fund
j 32e
f. Homeless Animal Prevention on Care
j 32f
Total: Add lines 32a through 32f
32
33. Use tax due on out-of-state purchases. If no use tax due enter "0"
j 33
0 b. Spouse j
0
34. Health care penalty a. You j
a + b = 34
35. INCOME TAX AFTER CREDITS PLUS CONTRIBUTIONS AND USE TAX. Add lines 31 through 34
35
36. Massachusetts income tax withheld
j 36
37. 2011 overpayment applied to your 2012 estimated tax
j 37
38. 2012 Massachusetts estimated tax payments
j 38
j 39
39. Payments made with extension
40. Earned Income Credit. a. No. of qualifying childrenj 0 Amount from U.S. return
j
x .15 = j 40
41. Senior Circuit Breaker Credit
j 41
42. Other Refundable Credits
j 42
43. TOTAL. Add lines 36 through 42
43
44. Overpayment. Subtract line 35 from line 43
j 44
45. Amount of overpayment you want applied to your 2013 estimated tax
j 45
46. Refund. Subtract line 45 from line 44. Mail to: Massachusetts DOR, PO Box 7001, Boston, MA 02204
j 46
Direct deposit of refund. Type of accountj
RTN #j
47.
account #
0
0
1064
860
860
checking
savings
j
Tax due. Pay online at www.mass.gov/dor/payonline. Mail to: Mass. DOR, PO Box 7002, Boston, MA 02204
Interest j
Penalty j
M-2210 amt. j
BE SURE TO INCLUDE THIS PAGE WITH FORM 1, PAGE 1
10/12/2013 11:38:11
MA1$$$$3
j
204
47
j
EX enclose
Form M-2210
2012 Schedule DI MA12SDI11045
MARY
BERINGER
031-01-6074
Schedule DI. Dependent Information
COREY
SON
Is dependent a qualifying child for earned income credit?
JOHNSON
ASIA
DAUGHTER
Is dependent a qualifying child for earned income credit?
ANGIE
PARENT
Is dependent a qualifying child for earned income credit?
JOHNSON
JESSE
033-01-6074
j X 10301996
032-01-6074
j X 02101995
034-01-6074
05201934
j
Is dependent a qualifying child for earned income credit?
j
Is dependent a qualifying child for earned income credit?
j
Is dependent a qualifying child for earned income credit?
j
Is dependent a qualifying child for earned income credit?
j
Is dependent a qualifying child for earned income credit?
j
Is dependent a qualifying child for earned income credit?
j
Is dependent a qualifying child for earned income credit?
j
10/12/2013 11:38:11
MADI$$$1
2012 Schedule HC MA1202911045
Schedule HC, Health Care Information, must be completed by
all full-year residents and certain part-year residents (see instr.).
Note: Schedule HC must be enclosed with your Form 1 or Form
1-NR/PY. Failure to do so will delay the processing of your return.
MARY
BERINGER
1a. Date of birth
j 12261953
1b.
Spouse's date of birth
031-01-6074
j
1c. Family size
j
4
j
2. Federal adjusted gross income
2
49884
3. Indicate the time period that you were enrolled in a Minimum Creditable Coverage (MCC) health insurance plan(s). The Form MA 1099-HC
from your insurer will indicate whether your insurance met MCC requirements. Note: MassHealth, Commonwealth Care, Commonwealth
Care Bridge, Medicare, and health coverage for U.S. Military, including Veterans Administration and Tri-Care, meet the MCC requirements.
If you did not receive a Form MA 1099-HC from your insurer, or you had insurance that did not meet MCC requirements, see the special
section on MCC requirements in the instructions.
X Full-year MCC
See instructions if, during 2012, you turned 18, you
j 3a You:
Part-year MCC
were part-year resident or a taxpayer was deceased.
j 3b Spouse:
Full-year MCC
Part-year MCC
If you filled in the full-year or part-year MCC space, go to line 4. If you filled in No MCC/None, go to line 6.
No MCC/None
No MCC/None
4. Indicate the health insurance plan(s) that met the Minimum Creditable Coverage (MCC) requirements in which you were enrolled in 2012, as
shown on Form MA 1099-HC (check all that apply). If you did not receive this form, fill in line(s) 4f and/or 4g and see instructions. Fill in if you
were enrolled in private insurance and MassHealth, Commonwealth Care or Commonwealth Care Bridge, and enter your private insurance
information in line(s) 4f and/or 4g and go to line 5.
X You
4a. Private insurance (completes line(s) 4f and/or 4g below). If more than two, complete Schedule HC-CS
Spouse
4b. MassHealth, Commonwealth Care or Commonwealth Care Bridge. Fill in and go to line 5
You
Spouse
4c. Medicare (including a replacement or supplemental plan). Fill in and go to line 5
You
Spouse
4d. U.S. Military (including Veterans Administration and Tri-Care). Fill in and go to line 5
You
Spouse
4e. Other government program (enter the program name(s) only in lines 4f and/or 4g below). Note: Health
You
Spouse
Safety Net is not considered insurance or minimum creditable coverage.
4f. Your Health Insurance. Complete if you answered line(s) 4a or 4e and go to line 5.
BLUE CROSS / BLUE SHIELD
96-0000061
4g. Spouse's Health Insurance. Complete if you answered line(s) 4a or 4e and go to line 5.
Fill in if you were not issued Form MA 1099-HC
031016074
Fill in if you were not issued Form MA 1099-HC
5. If you had health insurance that met MCC requirements for the full-year, including private insurance, MassHealth, Commonwealth Care or
Commonwealth Care Bridge, you are not subject to a penalty. Skip the remainder of this schedule and continue completing your tax return.
Otherwise, go to line 6.
If you had Medicare (including a replacement or supplemental plan), U.S. Military (including Veterans Administration and Tri-Care), or other
government insurance at any point during 2012, you are not subject to a penalty. Skip the remainder of this schedule and continue
completing your tax return. Otherwise, go to line 6.
10/12/2013 11:38:11
MAHC$$$1
2012 Schedule INC MA12INC11045
MARY
BERINGER
031-01-6074
Form W-2 and 1099 Information
A.FEDERAL ID
NUMBER
B.STATE TAX
WITHHELD
D.TAXPAYER SS
WITHHELD
C.STATE WAGES/
INCOME
11-0123456
860
35689
1499
TOTALS
860
35689
1499
10/12/2013 11:38:11
MAINC$$1
E.SPOUSE SS
WITHHELD
F. SOURCE OF
WITHHOLDING
W2
MAPV$$$1
Social Security number
j
j
Form PV
DETACH HERE
Massachusetts
Department of Revenue
Amount enclosed
Income Tax Payment Voucher - 2012
Spouse's Social Security number
031-01-6074
Year end date
12/12
204.00
Check which form you filed:
MARY
BERINGER
X
1040 WILSON LANE
WORCESTER MA 01601
Form 1
Form 1-NR/PY
Nonresident Composite Return
Name/address changed since 2010
Pay online at www.mass.gov/dor/payonline. Or, return this voucher with check or money order payable to:
Commonwealth of Massachusetts, and mail to: Massachusetts Department of Revenue, PO Box 7003, Boston, MA 02204.
031016074 2 020518 3 00000020400 8 1212 0140 136 5
V# 1045