Electronic Filing Instructions for your 2014 Federal Tax Return
Important: Your taxes are not finished until all required steps are completed.
Adrijan Delale
33 Somerset Lane
Nantucket, MA 02554
|
| Your federal tax return (Form 1040A) shows a refund due to you in the
| amount of $2,392.00. Applicable fees were deducted from your original
| refund amount of $2,392.00. Your refund is now $2,292.03. Because you
| chose to have your TurboTax fees deducted from your refund, you will
| receive e-mail from The Citizens Banking Company, which handles this
| transaction. Your tax refund will be direct deposited into your
| account. The account information you entered - Account Number:
| 004648363011 Routing Transit Number: 011000138.
______________________________________________________________________________________
|
|
When Will
| The IRS issued more than 9 out of 10 refunds to taxpayers in less
You Get
| than 21 days last year. The same results are expected in 2015. To
Your
| get your estimated refund date from TurboTax, log into My TurboTax at
Refund?
| www.turbotax.com. If you do not receive your refund within 21 days,
| or the amount you get is not what you expected, contact the Internal
| Revenue Service directly at 1-800-829-4477. You can also check
| www.irs.gov and select the "Where's my refund?" link.
______________________________________________________________________________________
|
|
What You
| Your Electronic Filing Instructions (this form)
Need to
| Printed copy of your federal return
Keep
|
______________________________________________________________________________________
|
|
2014
| Adjusted Gross Income
$
12,291.00
Federal
| Taxable Income
$
2,141.00
Tax
| Total Tax
$
0.00
Return
| Total Payments/Credits
$
2,392.00
Summary
| Amount to be Refunded
$
2,392.00
| Effective Tax Rate
-8.14%
______________________________________________________________________________________
|
Balance
Due/
Refund
Page 1 of 1
Hi Adrijan,
We just want to thank you for using TurboTax this year!
your taxes easy and accurate, year after year.
It's our goal to make
With TurboTax PLUS:
Breathe easy. The calculations on your return are backed with our
100% Accuracy Guarantee.
Here's the final wrap up for your 2014 taxes:
Your federal tax refund is:
$ 2,392.00
You qualified for these important credits:
- Education Credits
- We double checked your return for errors along the way.
- We helped with step-by-step guidance to get your answers on the right
IRS forms.
- We made sure you didn't miss a deduction even if something in your life
changed, like a new job, new house - or more kids!
Your Head Start On Next Year:
When you come back next year, taxes will be so easy! We'll have all
your information saved and ready to transfer in to your new return.
We'll ask you questions about what changed since we last talked, and
we'll be ready to get you the credits and deductions you deserve, no
matter what life throws at you.
Also included:
- We provide the Audit Support Center free of charge in the unlikely
event you get audited.
With TurboTax State:
- You saved time by automatically transferring your federal tax
information to your state return
Many happy returns from TurboTax.
Form
Department of the Treasury—Internal Revenue Service
1040A
U.S. Individual Income Tax Return (99)
Your first name and initial
2014
IRS Use Only—Do not write or staple in this space.
Last name
Adrijan
OMB No. 1545-0074
Your social security number
Delale
If a joint return, spouse’s first name and initial
782
Last name
Home address (number and street). If you have a P.O. box, see instructions.
Apt. no.
33 Somerset Lane
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions).
Filing
status
Check only
one box.
Exemptions
6455
c
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
Foreign postal code a box below will not change your tax or
refund.
You
Spouse
Nantucket MA 02554
Foreign country name
04
Spouse’s social security number
Foreign province/state/county
1
2
3
4
Single
Head of household (with qualifying person). (See instructions.)
Married filing jointly (even if only one had income)
If the qualifying person is a child but not your dependent,
enter this child’s name here. a
Married filing separately. Enter spouse’s SSN above and
a
Qualifying widow(er) with dependent child (see instructions)
5
full name here.
Boxes
6a
Yourself. If someone can claim you as a dependent, do not check
checked on
box 6a.
1
6a and 6b
No. of children
b
Spouse
on 6c who:
(4) if child under
c Dependents:
• lived with
(3) Dependent’s
}
(2) Dependent’s social
security number
If more than six
dependents, see
instructions.
(1) First name
relationship to you
Last name
age 17 qualifying for
child tax credit (see
instructions)
you
• did not live
with you due to
divorce or
separation (see
instructions)
Dependents
on 6c not
entered above
Add numbers
on lines
above a
d Total number of exemptions claimed.
1
Income
7
Attach
Form(s) W-2
here. Also
attach
Form(s)
1099-R if tax
was
withheld.
If you did not
get a W-2, see
instructions.
Wages, salaries, tips, etc. Attach Form(s) W-2.
7
8a Taxable interest. Attach Schedule B if required.
b Tax-exempt interest. Do not include on line 8a. 8b
Ordinary dividends. Attach Schedule B if required.
b Qualified dividends (see instructions).
9b
10 Capital gain distributions (see instructions).
11a IRA
11b Taxable amount
distributions.
11a
(see instructions).
12a Pensions and
12b Taxable amount
annuities.
12a
(see instructions).
8a
9a
10
11b
12b
13 Unemployment compensation and Alaska Permanent Fund dividends.
14a Social security
14b Taxable amount
benefits.
14a
(see instructions).
Adjusted
gross
income
15
Add lines 7 through 14b (far right column). This is your total income.
16
17
18
Educator expenses (see instructions).
IRA deduction (see instructions).
Student loan interest deduction (see instructions).
19
20
Tuition and fees. Attach Form 8917.
19
Add lines 16 through 19. These are your total adjustments.
21
Subtract line 20 from line 15. This is your adjusted gross income.
12,291.
13
14b
a
15
12,291.
16
17
18
20
a
21
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions.
BAA
12,291.
Form 1040A (2014)
REV 01/20/15 TTO
22
Page 2
12,291.
24
25
26
6,200.
6,091.
3,950.
27
2,141.
30
214.
36
37
38
39
214.
0.
46
2,392.
47
48a
2,392.
2,392.
Form 1040A (2014)
Tax, credits, 22 Enter the amount from line 21 (adjusted gross income).
You were born before January 2, 1950,
Blind Total boxes
23a Check
and
if:
Spouse
was
born
before
January
2,
1950,
Blind checked a 23a
payments
{
b If you are married filing separately and your spouse itemizes
a 23b
deductions, check here
24 Enter your standard deduction.
25 Subtract line 24 from line 22. If line 24 is more than line 22, enter -0-.
26 Exemptions. Multiply $3,950 by the number on line 6d.
27 Subtract line 26 from line 25. If line 26 is more than line 25, enter -0-.
a
This is your taxable income.
28 Tax, including any alternative minimum tax (see instructions). 28
214.
29 Excess advance premium tax credit repayment. Attach
Form 8962.
29
30 Add lines 28 and 29.
31 Credit for child and dependent care expenses. Attach
Form 2441.
31
32 Credit for the elderly or the disabled. Attach
Schedule R.
32
33 Education credits from Form 8863, line 19.
33
214.
34 Retirement savings contributions credit. Attach Form 8880. 34
35 Child tax credit. Attach Schedule 8812, if required.
35
36 Add lines 31 through 35. These are your total credits.
37 Subtract line 36 from line 30. If line 36 is more than line 30, enter -0-.
38 Health care: individual responsibility (see instructions). Full-year coverage
39 Add line 37 and line 38. This is your total tax.
40 Federal income tax withheld from Forms W-2 and 1099. 40
1,392.
41 2014 estimated tax payments and amount applied
from 2013 return.
41
42a Earned income credit (EIC).
42a
b Nontaxable combat pay election. 42b
43 Additional child tax credit. Attach Schedule 8812.
43
44 American opportunity credit from Form 8863, line 8.
44
1,000.
45 Net premium tax credit. Attach Form 8962.
45
a
46 Add lines 40, 41, 42a, 43, 44, and 45. These are your total payments.
47 If line 46 is more than line 39, subtract line 39 from line 46.
This is the amount you overpaid.
48a Amount of line 47 you want refunded to you. If Form 8888 is attached, check here a
Routing
a c Type:
Checking
Savings
a b
number 0 1 1 0 0 0 1 3 8
Account
a d
number 0 0 4 6 4 8 3 6 3 0 1 1
49 Amount of line 47 you want applied to your
2015 estimated tax.
49
50 Amount you owe. Subtract line 46 from line 39. For details on how to pay,
a
see instructions.
51 Estimated tax penalty (see instructions).
51
Standard
Deduction
for—
• People who
check any
box on line
23a or 23b or
who can be
claimed as a
dependent,
see
instructions.
• All others:
Single or
Married filing
separately,
$6,200
Married filing
jointly or
Qualifying
widow(er),
$12,400
Head of
household,
$9,100
If you have
a qualifying
child, attach
Schedule
EIC.
Refund
Direct
deposit?
See
instructions
and fill in
48b, 48c,
and 48d or
Form 8888.
Amount
you owe
Do you want to allow another person to discuss this return with the IRS (see instructions)?
Third party
designee
F
Sign
here
Joint return?
See instructions.
Keep a copy
for your records.
Paid
preparer
use only
}
0.
50
Yes. Complete the following.
No
Designee’s
Phone
Personal identification
a
a
a
name
no.
number (PIN)
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 accurately list all amounts and sources of income I received during the tax year. Declaration of preparer (other
than the taxpayer) is based on all information of which the preparer has any knowledge.
Your occupation
Daytime phone number
Your signature
Date
Student
Spouse’s signature. If a joint return, both must sign.
Print/type preparer's name
Firm's name a
Firm's address
Date
Preparer’s signature
(508)901-1919
Spouse’s occupation
Date
If the IRS sent you an Identity Protection
PIN, enter it
here (see inst.)
Check a
if
self-employed
PTIN
Firm's EIN a
Self-Prepared
Phone no.
a
REV 01/20/15 TTO
Form 1040A (2014)
Form
8863
Department of the Treasury
Internal Revenue Service (99)
Education Credits
(American Opportunity and Lifetime Learning Credits)
▶
Attachment
Sequence No. 50
Your social security number
Adrijan Delale
CAUTION
Part I
782-04-6455
Complete a separate Part III on page 2 for each student for whom you are claiming either credit
before you complete Parts I and II.
Refundable American Opportunity Credit
1
2
After completing Part III for each student, enter the total of all amounts from all Parts III, line 30 .
Enter: $180,000 if married filing jointly; $90,000 if single, head of
90,000.
household, or qualifying widow(er) . . . . . . . . . . . . .
2
3
Enter the amount from Form 1040, line 38, or Form 1040A, line 22. If you
are filing Form 2555, 2555-EZ, or 4563, or you are excluding income from
12,291.
Puerto Rico, see Pub. 970 for the amount to enter . . . . . . . .
3
Subtract line 3 from line 2. If zero or less, stop; you cannot take any
77,709.
education credit . . . . . . . . . . . . . . . . . . .
4
Enter: $20,000 if married filing jointly; $10,000 if single, head of household,
10,000.
5
or qualifying widow(er) . . . . . . . . . . . . . . . . .
If line 4 is:
• Equal to or more than line 5, enter 1.000 on line 6 . . . . . . . . . . . .
. . . .
• Less than line 5, divide line 4 by line 5. Enter the result as a decimal (rounded to
at least three places) . . . . . . . . . . . . . . . . . . . . .
4
5
6
7
8
}
Multiply line 1 by line 6. Caution: If you were under age 24 at the end of the year and meet
the conditions described in the instructions, you cannot take the refundable American opportunity
credit; skip line 8, enter the amount from line 7 on line 9, and check this box
. . . . ▶
Refundable American opportunity credit. Multiply line 7 by 40% (.40). Enter the amount here and
on Form 1040, line 68, or Form 1040A, line 44. Then go to line 9 below. . . . . . . . . .
Part II
9
10
11
12
13
14
15
16
17
18
19
2014
▶ Attach to Form 1040 or Form 1040A.
Information about Form 8863 and its separate instructions is at www.irs.gov/form8863.
Name(s) shown on return
!
▲
OMB No. 1545-0074
1
2,500.
6
1.000
7
2,500.
8
1,000.
9
1,500.
Nonrefundable Education Credits
Subtract line 8 from line 7. Enter here and on line 2 of the Credit Limit Worksheet (see instructions)
After completing Part III for each student, enter the total of all amounts from all Parts III, line 31. If
zero, skip lines 11 through 17, enter -0- on line 18, and go to line 19 . . . . . . . . . .
Enter the smaller of line 10 or $10,000 . . . . . . . . . . . . . . . . . . . .
Multiply line 11 by 20% (.20) . . . . . . . . . . . . . . . . . . . . . . .
Enter: $128,000 if married filing jointly; $64,000 if single, head of
household, or qualifying widow(er)
. . . . . . . . . . . . .
13
Enter the amount from Form 1040, line 38, or Form 1040A, line 22. If you
are filing Form 2555, 2555-EZ, or 4563, or you are excluding income from
Puerto Rico, see Pub. 970 for the amount to enter . . . . . . . .
14
Subtract line 14 from line 13. If zero or less, skip lines 16 and 17, enter -0on line 18, and go to line 19
. . . . . . . . . . . . . . .
15
Enter: $20,000 if married filing jointly; $10,000 if single, head of household,
or qualifying widow(er) . . . . . . . . . . . . . . . . .
16
If line 15 is:
• Equal to or more than line 16, enter 1.000 on line 17 and go to line 18
• Less than line 16, divide line 15 by line 16. Enter the result as a decimal (rounded to at least three
places) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Multiply line 12 by line 17. Enter here and on line 1 of the Credit Limit Worksheet (see instructions) ▶
Nonrefundable education credits. Enter the amount from line 7 of the Credit Limit Worksheet (see
instructions) here and on Form 1040, line 50, or Form 1040A, line 33 . . . . . . . . . .
For Paperwork Reduction Act Notice, see your tax return instructions.
BAA
10
11
12
17
18
19
REV 10/16/14 TTO
214.
Form 8863 (2014)
Page 2
Your social security number
Form 8863 (2014)
Name(s) shown on return
Adrijan Delale
!
▲
CAUTION
Part III
782-04-6455
Complete Part III for each student for whom you are claiming either the American
opportunity credit or lifetime learning credit. Use additional copies of Page 2 as needed for
each student.
Student and Educational Institution Information
See instructions.
20 Student name (as shown on page 1 of your tax return)
21 Student social security number (as shown on page 1 of your tax return)
Adrijan
Delale
22
Educational institution information (see instructions)
a. Name of first educational institution
782-04-6455
b. Name of second educational institution (if any)
American University in Bulgaria
(1) Address. Number and street (or P.O. box). City, town or
post office, state, and ZIP code. If a foreign address, see
instructions.
(1) Address. Number and street (or P.O. box). City, town or
post office, state, and ZIP code. If a foreign address, see
instructions.
1 Georgi Izmirliev Sq.
Blagoevgrad Blagoevgrad Bulgaria 2700
(2) Did the student receive Form 1098-T
(2) Did the student receive Form 1098-T
Yes
No
Yes
No
from this institution for 2014?
from this institution for 2014?
(3) Did the student receive Form 1098-T
(3) Did the student receive Form 1098-T
Yes
No
Yes
No
from this institution for 2013 with Box
from this institution for 2013 with Box 2
2 filled in and Box 7 checked?
filled in and Box 7 checked?
If you checked “No” in both (2) and (3), skip (4).
If you checked “No” in both (2) and (3), skip (4).
(4) If you checked “Yes” in (2) or (3), enter the institution's
(4) If you checked “Yes” in (2) or (3), enter the institution's
federal identification number (from Form 1098-T).
federal identification number (from Form 1098-T).
23
24
25
26
Has the Hope Scholarship Credit or American opportunity
credit been claimed for this student for any 4 tax years
before 2014?
Was the student enrolled at least half-time for at least one
academic period that began or is treated as having begun in
2014 at an eligible educational institution in a program
leading towards a postsecondary degree, certificate, or
other recognized postsecondary educational credential?
(see instructions)
Yes — Stop!
Go to line 31 for this student.
Did the student complete the first 4 years of post-secondary
education before 2014?
Yes — Stop!
Go to line 31 for this
student.
No — Go to line 26.
Was the student convicted, before the end of 2014, of a
felony for possession or distribution of a controlled
substance?
Yes — Stop!
Go to line 31 for this
student.
No — Complete lines 27
through 30 for this student.
▲
!
CAUTION
Yes — Go to line 25.
No — Go to line 24.
No — Stop! Go to line 31
for this student.
You cannot take the American opportunity credit and the lifetime learning credit for the same student in the same year. If
you complete lines 27 through 30 for this student, do not complete line 31.
American Opportunity Credit
27
28
29
30
Adjusted qualified education expenses (see instructions). Do not enter more than $4,000 . . .
Subtract $2,000 from line 27. If zero or less, enter -0- . . . . . . . . . . . . . . . .
Multiply line 28 by 25% (.25) . . . . . . . . . . . . . . . . . . . . . . . .
If line 28 is zero, enter the amount from line 27. Otherwise, add $2,000 to the amount on line 29
enter the result. Skip line 31. Include the total of all amounts from all Parts III, line 30 on Part I, line 1
.
.
.
and
.
27
28
29
4,000.
2,000.
500.
30
2,500.
Lifetime Learning Credit
31
Adjusted qualified education expenses (see instructions). Include the total of all amounts from all Parts
III, line 31, on Part II, line 10 . . . . . . . . . . . . . . . . . . . . . . . . .
31
Form 8863 (2014)
Form
8965
Department of the Treasury
Internal Revenue Service
OMB No. 1545-0074
Health Coverage Exemptions
a
2014
a Attach to Form 1040, Form 1040A, or Form 1040EZ.
Information about Form 8965 and its separate instructions is at www.irs.gov/form8965.
Name as shown on return
Attachment
Sequence No. 75
Your social security number
Adrijan Delale
782-04-6455
Complete this form if you have a Marketplace-granted coverage exemption or you are claiming a coverage exemption
on your return.
Part I
Marketplace-Granted Coverage Exemptions for Individuals: If you and/or a member of your tax household
have an exemption granted by the Marketplace, complete Part I.
a
Name of Individual
b
SSN
c
Exemption Certificate Number
1
2
3
4
5
6
Part II
7a
b
Coverage Exemptions for Your Household Claimed on Your Return:
Are you claiming an exemption because your household income is below the filing threshold? .
.
Are you claiming a hardship exemption because your gross income is below the filing threshold?
Part III
.
.
.
.
Yes
No
.
.
.
.
Yes
No
Coverage Exemptions for Individuals Claimed on Your Return: If you and/or a member of your tax
household are claiming an exemption on your return, complete Part III.
a
Name of Individual
b
SSN
c
d
Exemption Full
Type
Year
8
Adrijan Delale
782-04-6455 G
9
Adrijan Delale
782-04-6455 B
e
Jan
f
Feb
g
Mar
h
Apr
i
j
k
May June July
l
Aug
m
Sept
n
Oct
o
Nov
p
Dec
10
11
12
13
For Privacy Act and Paperwork Reduction Act Notice, see your tax return instructions.
BA
REV 11/26/14 TTO
Form 8965 (2014)
Tax History Report
2014
G Keep for your records
Name(s) Shown on Return
Adrijan Delale
Five Year Tax History:
2010
2011
2012
Filing status
2013
2014
Single
Total income
12,291.
Adjustments to income
Adjusted gross income
12,291.
Tax expense
638.
Interest expense
Contributions
Miscellaneous
deductions
Other Itemized
Deductions
Total itemized/
standard deduction
6,200.
Exemption amount
3,950.
Taxable income
2,141.
Tax
214.
Alternative min tax
Total credits
214.
Other taxes
Payments
2,392.
Form 2210 penalty
Amount owed
Applied to next
year’s estimated tax
Refund
2,392.
Effective tax rate %
-8.14
**Tax bracket %
10.0
Preparation fee
**Tax bracket % is based on Taxable income.
CUSTOMER SERVICE: 877-908-7228
The Citizens Banking Company Refund Processing Agreement (’Agreement’)
Name
Social Security No.
Adrijan Delale
782-04-6455
This Agreement contains important terms, conditions and disclosures about the processing of your refund by
The Citizens Banking Company of Sandusky, OH ("BANK"). Read this Agreement carefully before accepting
its terms and conditions, and print a copy and/or retain this information electronically for future reference. As
used in this Agreement, the words ’you’ and ’your’ refer to the applicant or both the applicant and joint
applicant if the 2014 federal income tax return is a joint return (individually and collectively, ’Applicant’).
The words ’we,’ ’us’ and ’our’ refer to BANK. The term ’Servicer’ or "Processor’ refer to the third party
processor, Santa Barbara Tax Products Group, LLC.
1. NOTICE: No Requirement To Have BANK Process Your Refund In Order To File Electronically.
IF YOU USE THE REFUND PROCESSING SERVICE, YOU CAN EXPECT TO RECEIVE THE PROCEEDS FROM
YOUR FEDERAL TAX REFUND WITHIN 21 DAYS FROM WHEN THE IRS ACCEPTS YOUR RETURN UNLESS
THERE ARE PROCESSING DELAYS BY THE IRS. THE REFUND PROCESSING SERVICE WILL NEITHER
SPEED UP NOR DELAY YOUR FEDERAL TAX REFUND. IF YOU DO NOT USE THE REFUND PROCESSING
SERVICE, BUT DO FILE YOUR TAX RETURN ELECTRONICALLY, AND HAVE YOUR TAX REFUND DIRECTLY
DEPOSITED INTO A BANK ACCOUNT, YOU CAN EXPECT TO RECEIVE YOUR REFUND WITHIN 21 DAYS
FROM WHEN THE IRS ACCEPTS YOUR RETURN UNLESS THERE ARE PROCESSING DELAYS BY THE IRS.
IF YOU ELECT TO RECEIVE YOUR FEDERAL TAX REFUND THROUGH THE MAIL, YOU CAN EXPECT
EXPECT TO RECEIVE YOUR REFUND IN 3 TO 4 WEEKS FROM WHEN THE IRS ACCEPTS YOUR RETURN.
THE COST OF PREPARING YOUR TAX RETURN IS NOT ANY MORE OR LESS IF YOU PURCHASE THE
REFUND PROCESSING SERVICE.
2. Authorization to Release Personal Information.
You authorize the Internal Revenue Service (’IRS’) to
disclose any information to BANK and Processor related to the funding of your 2014 federal tax refund.
You also authorize Intuit, as the transmitter of your electronically filed tax return, to disclose your tax return
and contact information to BANK and Processor for use in connection with the refund processing services
being provided pursuant to this Agreement and BANK to share your information with Intuit. Neither Intuit,
BANK nor Processor will disclose or use your tax return information for any other purpose, except as
permitted by law. BANK and Processor will not use your tax information or contact information for any
marketing purpose. For more information concerning our privacy policy please see the disclosures at the end
of this Agreement describing how BANK may use or share your personal information.
3.
Summary of Terms
Expected Federal Refund
Less TurboTax Fees
Less Additional Products and Services Purchased
Expected Proceeds*
$
$
$
$
2,392.00
59.98
39.99
2,292.03
*These charges are itemized. This is only an estimate. The amount will be reduced by any applicable sales taxes, and if
applicable, a returned item and other processing fee paid to BANK’s Processor as set forth in paragraphs 4 and 7 below.
Adrijan Delale
782-04-6455
Page 2
4. Temporary Deposit Account Authorization. You hereby authorize BANK to establish a temporary deposit
account (’Deposit Account’) for the purpose of receiving your tax year 2014 federal tax refund from the
IRS. BANK or Processor must receive an acknowledgement from the IRS that your return has been
electronically filed and accepted for processing before the Deposit Account can be opened. You authorize
BANK or Processor to deduct from your Deposit Account the following amounts: (i) the fees and charges
related to the preparation, processing and transmission of your tax return (TurboTax Fees); and, (ii) amounts
to pay for additional products and services purchased plus applicable taxes. You also authorize BANK or
Processor to deduct twenty dollars ($20) as a returned item processing fee from your Deposit Account in the
event that your deposit is returned or you provide incorrect bank account or routing information, as set forth
in the Note below paragraph 7 below. This fee shall be paid by BANK to its Processor. You authorize BANK
and Processor to disburse the balance of the Deposit Account to you after making all authorized deductions
or payments. If the Deposit Account does not have sufficient funds to pay the TurboTax fees and the fees
for Additional Products and Services Purchased as set forth in Section 3, (a) You authorize BANK to
automatically deduct such fees (or any portion thereof) via ACH, electronic check, or wire transfer directly
from the account or card in which You authorized BANK to deposit your Expected Proceeds as set forth in
Section 7, and (b) if you made alternative arrangements with TurboTax for payment of such fees, those
arrangements will be attempted prior to any automatic deduction.
5. Acknowledgements.
(a) You understand that: (i) BANK cannot guarantee the amount of your tax year
2014 federal tax refund or the date it will be issued, and (ii) Neither BANK nor Processor is affiliated with
the transmitter of the tax return (Intuit) and neither warrants the accuracy of the software used to prepare
the tax return. (b) You agree that Intuit is not acting as your agent and is not under any fiduciary duty with
respect to the processing of your refund by BANK and Processor.
6. Truth in Savings Disclosure. The Deposit Account is being opened for the purpose of receiving your
(both spouses if this is a jointly filed return) tax year 2014 federal tax refund. No other deposits may be
made to the Deposit Account. No withdrawals will be allowed from the Deposit Account except as provided
in Section 4. No interest is payable on the funds on the deposit; thus, the annual percentage yield and
interest rate are 0%. The Deposit Account will be closed after all authorized deductions have been made
and any remaining balance has been disbursed to you. We will also charge a Return Item Fee of $20 if the
refund cannot be delivered as directed in Section 4 of this application. an Account Research and Legal
Processing fee of $25 may be charged if we are required to provide additional processing to return the funds
to the IRS. These fees will be paid by BANK to its Processor. Questions or concerns about the Deposit
Account should be directed to: The Citizens Banking Company, c/o Santa Barbara Tax Products Group, LLC,
11085 North Torrey Pines Road, Suite 210, La Jolla, CA 92037 or via the Internet at http://cisc.sbtpg.com.
7. Disbursement Method: You agree that the disbursement method selected below will be used by BANK to
disburse funds to you.
a
Direct Deposit to Prepaid Debit Card: If you choose this option, you authorize BANK to transfer
the balance of your Deposit Account to the financial institution that supports your prepaid debit card,
so that the financial institution may deposit the balance of your refund, as directed by you, on the
respective prepaid debit card you have selected. Additional fees may be charged for the use of the
card. Please review the cardholder agreement associated with the use of your prepaid debit card
provided by the participating financial institution to learn of other fees, charges, terms and conditions
that will apply. BANK will not be responsible for your funds once they have been deposited with the
respective financial institution.
b
X Direct Deposit to Checking or Savings Account: If you choose this option, the balance of your
Deposit Account will be disbursed to you electronically by ACH Direct Deposit to your personal bank
account designated below. If a joint return is filed, the bank account may be a joint account or the
individual account of either spouse.
DIRECT DEPOSIT ACCOUNT TYPE:
X Checking
Savings
RTN #
Account #
011000138
004648363011
Note: To ensure that there are no delays in receiving your refund, please contact your financial
institution to confirm that you are using the correct RTN (routing) and account number. If you or your
representative enter your account information incorrectly and your deposit is returned to BANK, the
Deposit Account balance minus a $20 returned item processing fee will be disbursed to you via a
cashier’s check mailed to your physical address of record. The BANK, the processor or Intuit is not
responsible for the misapplication of a direct deposit that results from error, negligence or malfeasance
on the part of you or your representative. The BANK will make every effort to deliver your Deposit
Account balance to you. In cases where BANK has received your federal tax refund but is unable to
deliver the funds directly to you, funds may be held at the BANK until claimed, or returned to the IRS
or State of residency. Additional return item and processing fees may be deducted from the Deposit
Account for federal tax refunds that continue to be undeliverable and unclaimed and must be returned
to the IRS or State. The amount of additional processing fees will be determined by the efforts
required and the complexity of the transaction but will not exceed $25. Processing fees will be paid by
BANK to Processor.
You must notify BANK in writing 3 business days prior to the account being debited to revoke the
authorization for applicable fees agreed to in Section 4, and to afford BANK a reasonable opportunity to act
on your request. You may notify us in writing at: The Citizens Banking, c/o Santa Barbara Tax Products
Group, LLC, 11085 North Torrey Pines Road, Suite 210, La Jolla, California 92037.
Adrijan Delale
782-04-6455
Page 3
8. FEDERAL ELECTRONIC FUND TRANSFER ACT DISCLOSURES: The Federal Electronic Fund Transfer Act
provides you with certain rights and obligations regarding the Federal and state income tax refund that will
be electronically deposited into your Account established at The Citizens Banking Company for that purpose.
If you believe that there is an error or if you have a question about your Account, write to The Citizens
Banking Company, c/o Santa Barbara Tax Products, Group, LLC, 11085 North Torrey Pines Road, Suite
210, La Jolla, California 92037 or telephone (877) 908-7228 and provide The Citizens Banking Company with
your name, a description or explanation of the error and the dollar amount of the suspected error. The
Citizens Banking Company will advise you of the results of its investigation within 10 business days.
Business Days: Our business days are Monday through Friday, excluding federal holidays. Saturday,
Sunday, and federal holidays are not considered business days, even if we are open.
Confidentiality: We will disclose information to third parties about your account or the transfers you make:
? To complete transfers as necessary;
? To verify the existence and condition of your account upon the request of a third party, such as a credit
bureau or merchant; or
? To comply with government agency or court orders; or
? If you give us your written permission; or
? As explained in the Privacy section of this disclosure
Our Liability: If we do not complete a transfer to your account on time or in the correct amount according to
our agreement with you, we may be liable for your losses or damages. In addition to all other limitations of
our liability set forth in this Agreement, we will not be liable to you if, among other things:
? Circumstances beyond our control (natural disasters, such as fire or flood) prevent the transfer, despite
reasonable precautions that we have taken.
? The funds in your account are subject to legal process or other claim restricting such transfer.
9. Governing Law. The enforcement and interpretation of this Agreement and the transactions
contemplated herein shall be governed by the laws of the United States, including the Electronic Signatures
in Global and National Commerce Act, and, to the extent state law applies, the substantive law of Ohio.
10. Arbitration Provision. This arbitration provision is made pursuant to a transaction involving interstate
commerce and shall be governed by the Federal Arbitration Act. You agree that any and all disputes which
in any way arise out of or relate to this Agreement, shall be resolved solely by binding arbitration before the
American Arbitration Association (’AAA’) before a single arbitrator in arbitration commenced as close as
possible to where you reside. Any and all disputes must be brought in the parties’ individual capacity, and
not as a plaintiff or class member in any purported class or representative proceeding. Judgment on the
award rendered by the arbitrator may be entered in any court having jurisdiction thereof. Each party to any
such arbitration shall bear its own separate costs and expenses of the arbitration and shall share equally in
the charges of the AAA, including the fee of the arbitrator. However, if you are unable to pay any fee of the
AAA or the arbitrator, Bank or Processor agrees to pay those fees for you. By agreeing to arbitration, you,
Bank and Processor are waiving our rights to file a lawsuit and proceed in court and to have a jury trial to
resolve disputes. The word ’disputes’ is given its broadest possible meaning, and includes all claims;
disputes or controversies, including without limitation any claim or attempt to set aside this arbitration
provision.
11. USA Patriot Act Disclosure. To help the government fight the funding of terrorism and money laundering
activities. Federal law requires all financial institutions to obtain, verify, and record information that identifies
each person who opens an account. What this means for you: When we open a Deposit Account for you for
the purpose of receiving your IRS federal tax refund or if you apply for one of our products, we will ask for
your name, address, date of birth, and other information that will allow us to identify you. We may also ask
for your driver’s license information or information from other identifying documents of yours.
YOUR AGREEMENT
BANK and Processor agree to all of the terms of this Agreement. By selecting the
'I Agree' button in
TurboTax: (i) You authorize BANK to receive your 2014 federal tax refund from the IRS and to make the
deductions from your refund described in the Agreement, (ii) You agree to receive all Communications
electronically in accordance with the ’Consent to Conduct Business Electronically’ section of the License
Agreement for Tax Year 2014 TurboTax(R) Software and Services, as the term ’Communications’ is
defined therein, (iii) You consent to the release of your 2014 federal tax refund deposit information and
application information as described in Section 2 of this Agreement; and (iv) You acknowledge that you have
reviewed, and agree to be bound by, the Agreement’s terms and conditions. If this is a joint return, selecting
'I Agree' indicates that both spouses agree to be bound by the terms and conditions of this Agreement.
Adrijan Delale
782-04-6455
CUSTOMER SERVICE 877-908-7228
The Citizens Banking Company’s Tax Product Privacy Policy
FACTS
What does The Citizens Banking Company do with your Personal Information?
Why?
Financial Companies choose how they share your personal information. Federal law gives
consumers the right to limit some but not all sharing. Federal law also requires us to tell you how
we collect, share, and protect your personal information. Please read this notice carefully to
understand what we do.
What?
The types of personal information that we collect and share depend on the product or service you
have with us. This can include:
? Social Security number and account balances
? payment history and transaction history
? overdraft history and account transactions
When you are no longer our customer, we continue to share your information as described in
this notice.
How?
All Financial Companies need to share customers’ personal information to run their everyday
business. In the section below we list the reasons financial companies can share their
customers’ personal information; the reasons The Citizens Banking Company chooses to share
and whether you can limit the sharing.
Reasons we can share your
personal information
For our everyday business purposes
such as to process your transaction,
maintain your account(s), respond to court
orders and legal investigations, or report to
credit bureaus.
Does The Citizens Banking
Company Share?
Can you limit this sharing?
Yes
No
For our marketing purposes '
to offer our products and services to you.
No
We don’t share
For joint marketing with other
financial companies.
No
We don’t share
No
We don’t share
For our affiliates’ everyday
business purposes '
information about your creditworthiness.
No
We don’t share
For our affiliates to market to you.
No
We don’t share
For non affiliates to market to you.
No
We don’t share
For our affiliates’ everyday
business purposes '
information about your transactions
and experiences.
Questions?
Toll Free: 877-908-7228 or go to www.citizensbankco.com
Adrijan Delale
782-04-6455
Page 2
Who we are
Who is providing this notice?
The Citizens Banking Company
What we do
How does The Citizens Banking
Company protect my
personal information?
To protect your personal information from unauthorized access
and use, we use security measures that comply with federal law.
These measures include computer safeguards and secured files
and buildings.
How does The Citizens Banking
Company collect my
personal information?
We collect personal information about you when you apply for a tax
related product. This includes information in your application, such
as your name, address, social security number, income, deductions,
refund and the like. We also collect information about your
transactions with us, tax preparers and similar providers, such as
payment histories, balances due, and tax information. We may also
collect information concerning your credit history from a consumer
reporting agency.
Why can’t I limit all sharing?
Federal law gives you the right to limit only:
? Sharing for affiliates everyday business purposes ' information
about your creditworthiness,
? Affiliates from using your information to market to you,
? Sharing for non affiliates to market to you.
State laws and individual companies may give you additional rights
to limit sharing.
Definitions
Affiliates
Companies related by common ownership or control. They can be
financial and nonfinancial companies.
? The Citizens Banking Company does not share with our affiliates.
Non affiliates
Companies not related by common ownership or control. They can
be financial or nonfinancial companies.
? The Citizens Banking Company does not share with non
affiliates so they can market to you.
Joint Marketing
A formal joint marketing agreement between non affiliated
financial companies that together market financial products or
services to you.
? The Citizens Banking Company does not jointly market.
Other Important Information
This Notice is adopted in recognition of our obligations under Title V of Gramm-Leach Bliley Act of 1999.
This Notice applies only to individuals who have applied for a tax-related bank product.
sbia2301.SCR 12/21/14
Consent to Use of Tax Return Information
Federal law requires this consent form be provided to you. Unless authorized by law we cannot use
your tax return information for purposes other than the preparation and filing of your tax return
without your consent.
You are not required to complete this form to engage our tax return preparation services.
If we obtain your signature on this form by conditioning our tax return preparation services
on your consent, your consent will not be valid. Your consent is valid for the amount of time
that you specify. If you do not specify the duration of your consent, your consent is valid for one year
from the date of signature.
If you are requesting use of personal information from a joint return, you are representing that we
have consent for both parties on the return.
If you believe your tax return information has been disclosed or used improperly in a manner
unauthorized by law or without your permission, you may contact the Treasury Inspector General for
Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by email at complaints@tigta.treas.gov.
The following statements apply:
I authorize Intuit, the maker of TurboTax, to use my 2014 tax
return information to determine if I am eligible for:
- Added ways to get my refund, refund bonus
- Extra benefits beyond my refund
- IRA contribution options
Sign this agreement by entering your name and the date below.
Adrijan
Delale
First Name
Last Name
04/15/2015
Date
SBIA1001.SCR 11/11/14
Read and accept this Disclosure Consent
This is an IRS requirement
In order to finalize your request for this payment option, we need to send the following information to
The Citizens Banking Company of Sandusky, OH (’BANK’) and to Santa Barbara Tax Products Group
(’SBTPG’), the administrator and servicer of this payment option: your identifying information and your
refund amount.
We transmit this information using bank-level security for the sole purpose of providing you with this
payment option. Both the BANK and SBTPG will protect your confidentiality and use your information
only per the refund processing agreement and their privacy policies.
IRS regulations require the following statements:
"Federal law requires this consent form be provided to you. Unless authorized by law, we cannot
disclose your tax return information to third parties for purposes other than the preparation and filing of
your tax return without your consent. If you consent to the disclosure of your tax return information,
Federal law may not protect your tax return information from further use or distribution.
You are not required to complete this form to engage our tax return preparation services. If we obtain
your signature on this form by conditioning our tax return preparation services on your consent, your
consent will not be valid. If you agree to the disclosure of your tax return information, your consent is
valid for the amount of time that you specify. If you do not specify the duration of your consent, your
consent is valid for one year from the date of signature."
If you are requesting disclosure of personal information from a joint return, you are representing that
we have consent for both parties on the return.
If you believe your tax return information has been disclosed or used improperly in a manner
unauthorized by law or without your permission, you may contact the Treasury Inspector General for
Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by email at complaints@tigta.treas.gov.
To agree, enter your name and date in the boxes below and select the "I Agree" button on the
bottom of the page.
I authorize Intuit, the maker of TurboTax, to disclose to BANK and SBTPG that portion of my tax
return information that is necessary to enable BANK and SBTPG to process my 2014 refund
and pay my fees.
Sign this agreement by entering your name:
Adrijan
Please type the date below:
04/15/2015
Date
sbia1301.SCR 11/12/14
Delale
Form 1095-OTH
Health Insurance Coverage
2014
G Keep for your records
QuickZoom to Form 1095-A, Health Insurance Marketplace Statement
QuickZoom to Form 1095-B, Health Coverage
QuickZoom to Form 1095-C, Employer-Provided Health Insurance Offer and Coverage
QuickZoom to Form 1095, Worksheet
QuickZoom to Form 8962, Premium Tax Credit (PTC)
QuickZoom to Form 8965, Health Coverage Exemptions
Health Insurance Coverage for Individuals - This form may be used to report health insurance coverage information
for each individual whose health coverage is NOT reported on a Form 1095-A. If reporting an individual’s periods of
coverage from Form 1095-B or Form 1095-C, that individual’s health coverage information should not be reported below.
Check the box to populate the Name, SSN, and DOB for everyone listed on the return below.
Note: Checking this box again will repopulate the information below and overwrite existing entries.
Covered Individual:
a. Name of covered individual(s)
b. SSN
c. DOB
Covered all
12 months Jan
Feb Mar Apr May Jun
Jul
Aug Sep Oct Nov Dec
17 Adrijan
782-04-6455
18
19
20
21
22
10/14/92
X
X
X
X
X
X
1098-T
Tuition Statement
Worksheet
G Keep for your records
2014
Taxpayer’s name
Social Security No.
Adrijan Delale
782-04-6455
1098-T Information (Required):
A A Form 1098-T was received from this institution
Yes
B A Form 1098-T was received from this institution for 2013 with Box 2 filled in and
Box 7 checked
Yes
Identify Student (Required):
A If student is Adrijan
Double-click to link this 1098-T to the applicable Taxpayer or Spouse
Student Information Worksheet
Adrijan
B If student is
Double-click to link this 1098-T to the applicable Dependent Student
Information Worksheet
Filer’s name
1
American University in Bulgaria
Payments received for qualified
tuition and related expenses
$
Amounts billed for qualified tuition
and related expenses
$
No
X
No
X
12,000.
Street address
1 Georgi Izmirliev Sq.
City
State
Zip Code
2
Blagoevgrad
Foreign province/county
Blagoevgrad
Foreign postal code
Foreign country
2700
Bulgaria
Filer’s Federal
identification number
Student’s
Social Security Number.
3
If this box is checked, your educational institution
has changed its reporting method for 2014
4
Adjustments made for a
prior year
782-04-6455
$
Student’s name
6
Adrijan
Street address
5
Apt. No.
Scholarships or grants
$
Adjustments to
scholarships or grants
for a prior year
7
Checked if a graduate
student
10
Checked if the amount
in box 1 or 2 includes
amounts for an
academic period
beginning January March 2015
33 Somerset Lane
City
State
Nantucket
MA
Service Provider/ Acct No
Zip Code
02554
8 Check if at least
half-time student
$
9
Ins. contract reimb./refund
$
Reconciliation of Box 1, Payments Received for Qualified Tuition and Related Expenses
A
B
Enter box 1 amount not paid during 2014
Enter box 1 amount actually paid during 2014
Reconciliation of Box 2, Amounts Billed for Qualified Tuition and Related Expenses
A
B
Enter box 2 amount not paid during 2014
Enter box 2 amount actually paid during 2014
Reconciliation of Box 5, Scholarships or Grants
A
B
C
D
Enter portion of box 5 amount from veteran- or tax free employer-provided assistance
Enter portion of box 5 amount already included in income (on Forms W-2, 1099-MISC)
Portion of box 5 amount from scholarships or grants
Box 5 amount includes veteran- or employer-provided educational assistance
0.
12,000.
Tax Payments Worksheet
2014
G Keep for your records
Name(s) Shown on Return
Social Security Number
Adrijan Delale
782-04-6455
Estimated Tax Payments for 2014 (If more than 4 payments for any state or locality, see Tax Help)
Federal
Date
Amount
State
Date
Amount
Local
ID
Date
Amount
1
04/15/14
04/15/14
04/15/14
2
06/16/14
06/16/14
06/16/14
3
09/15/14
09/15/14
09/15/14
4
01/15/15
01/15/15
01/15/15
ID
5
Tot Estimated
Payments
Tax Payments Other Than Withholding
(If multiple states, see Tax Help)
6
7
8
9
Federal
ID
Local
ID
Overpayments applied to 2014
Credited by estates and trusts
Totals Lines 1 through 7
2014 extensions
Taxes Withheld From:
10
11
12
13
14
15
16
17
18 a
b
c
d
e
f
19
Forms W-2
Forms W-2G
Forms 1099-R
Forms 1099-MISC and 1099-G
Schedules K-1
Forms 1099-INT, DIV and OID
Social Security and Railroad Benefits
Form 1099-B
St
Loc
Other withholding
St
Loc
Other withholding
St
Loc
Other withholding
St
Loc
Positive Adjustment
St
Loc
Negative Adjustment
St
Loc
Additional Medicare Tax
Total Withholding Lines 10 through 18f
20
Total Tax Payments for 2014
Prior Year Taxes Paid In 2014
(If multiple states or localities, see Tax Help)
21
22
23
24
State
Tax paid with 2013 extensions
2013 estimated tax paid after 12/31/2013
Balance due paid with 2013 return
Other (amended returns, installment payments, etc)
Federal
State
Local
1,392.
638.
1,392.
1,392.
638.
638.
State
ID
Local
ID
Education Tuition and Fees Summary
2014
G Keep for your records
Name(s) Shown on Return
Your Social Security No.
Adrijan Delale
782-04-6455
Part I - Qualified Education Expense Summary
(a)
Student’s name
First Name
Last Name
Social Security Number
MI
Suffix
(b)
Qualified
Education
Expenses
(c)
Qualified
for:
Yes
No
(d)
Elected
Credit or
Deduction
if
manual
Amer Opp Cr
X
Lifetime Cr
X
Tuition Ded
X
Total Qualified Expenses
Amer Opp Cr
Lifetime Cr
Tuition Ded
Total Qualified Expenses
Amer Opp Cr
Lifetime Cr
Tuition Ded
Total Qualified Expenses
Adrijan
Delale
782-04-6455
12,250.
12,250.
12,250.
12,250.
Total qualified expenses
12,250. Amer Opp Cr
12,250. Lifetime Cr
12,250. Tuition Ded
(e)
Elected
Credit or
Deduction
if
automatic
X
Part II - Optimize Education Expenses for the Lowest Tax
Automatic
1
Launch OPTIMIZER - Check to launch Automatic Education Expense Optimizer now
2
Automatic - Check to use the Credit choices calculated in Part I, column (e) above
or
Manual - Check to use the Credit choices you entered in Part I, column (d) above
3
X
Part III - Summary of Deduction and Credits
Tuition and Fees Deduction Summary
1
2
3
4
Total 2014 tuition and fees paid for purposes of deduction
Modified adjusted gross income
Maximum deduction allowed
Allowable Tuition and Fees Deduction (lesser of line 1 or line 3)
1
2
3
4
0.
American Opportunity, Lifetime Learning Credits Summary
5
6
7
Tentative American Opportunity Credit
Tentative Lifetime Learning Credit
Total Education Credits (after limitations)
5
6
7
2,500.
1,214.
Federal Carryover Worksheet
2014
G Keep for your records
Name(s) Shown on Return
Social Security Number
Adrijan Delale
782-04-6455
2013 State and Local Income Tax Information (See Tax Help)
(a)
State or
Local ID
(b)
Paid With
Extension
(c)
Estimates Pd
After 12/31
(d)
Total Withheld/Pmts
(e)
Paid With
Return
(f)
Total Overpayment
(g)
Applied
Amount
Totals
Other Tax and Income Information
1
2
3
4
5
6
7
8
2013
Filing status
Number of exemptions for blind or over 65 (0 - 4)
Itemized deductions
Check box if required to itemize deductions
Adjusted gross income
Tax liability for Form 2210 or Form 2210-F
Alternative minimum tax
Federal overpayment applied to next year estimated tax
1
2
3
4
5
6
7
8
2014
1 Single
638.
12,291.
0.
QuickZoom to the IRA Information Worksheet for IRA information
Excess Contributions
9a
b
10 a
b
11 a
b
Taxpayer’s excess Archer MSA contributions as of 12/31
Spouse’s excess Archer MSA contributions as of 12/31
Taxpayer’s excess Coverdell ESA contributions as of 12/31
Spouse’s excess Coverdell ESA contributions as of 12/31
Taxpayer’s excess HSA contributions as of 12/31
Spouse’s excess HSA contributions as of 12/31
2014
2013
2012
2011
2010
2009
2014
2013
2014
9a
b
10 a
b
11 a
b
Loss and Expense Carryovers
Note: Enter all entries as a positive amount
12 a Short-term capital loss
b AMT Short-term capital loss
13 a Long-term capital loss
b AMT Long-term capital loss
14 a Net operating loss available to carry forward
b AMT Net operating loss available to carry forward
15 a Investment interest expense disallowed
b AMT Investment interest expense disallowed
16 Nonrecaptured net Section 1231 losses from:
a
b
c
d
e
f
2013
12 a
b
13 a
b
14 a
b
15 a
b
16 a
b
c
d
e
f
Electronic Filing Instructions for your 2014 Massachusetts Tax Return
Important: Your taxes are not finished until all required steps are completed.
Adrijan Delale
33 Somerset Lane
Nantucket, MA 02554
|
| Your Massachusetts state tax return (Form 1) shows a refund due to
| you in the amount of $638.00. Your tax refund will be direct
| deposited into your account. The account information you entered | Account Number: 004648363011 Routing Transit Number: 011000138.
______________________________________________________________________________________
|
|
Where's My
| Before you call the Massachusetts Department of Revenue with
Refund?
| questions about your refund, give them 21 days processing time from
| the date your return is accepted. If then you have not received your
| refund, or the amount is not what you expected, contact the
| Massachusetts Department of Revenue directly at 1-617-887-6367. You
| can also visit the Massachusetts Department of Revenue web site at
| http://www.dor.state.ma.us/.
______________________________________________________________________________________
|
|
No
| No signature form is required since you signed your return
Signature
| electronically.
Document
|
Needed
|
______________________________________________________________________________________
|
|
What You
| Your Electronic Filing Instructions (this form)
Need to
| Printed copy of your state and federal returns
Keep
| Forms W-2, W-2G, and 1099R ( if applicable )
______________________________________________________________________________________
|
|
2014
| Taxable Income
$
0.00
Massachusetts | Total Tax
$
0.00
Tax
| Total Payments/Credits
$
638.00
Return
| Amount to be Refunded
$
638.00
Summary
|
______________________________________________________________________________________
|
Balance
Due/
Refund
Page 1 of 1
2014 Form 1 MA1400111555
Massachusetts Resident Income Tax Return
FOR FULL YEAR RESIDENTS ONLY
For the year January 1–December 31, 2014 or other taxable
Year beginning
Ending
ADRIJAN
33 SOMERSET LANE
DELALE
782-04-6455
NANTUCKET
MA 02554
Apt. no.
State Election Campaign Fund:
$1 You
$1 Spouse TOTAL 3 0
Fill in if veteran of U.S. armed forces who served in Operation Enduring Freedom, Iraqi Freedom or Noble Eagle 3
You 3
Spouse
You
Spouse
Taxpayer deceased
3
Fill in if under age 18
3
You 3
Spouse
3
Name/address changed since 2013
12291
3
Fill in if noncustodial parent
Federal adjusted gross income
3
1. Filing status (select one only): 3 X Single
3
Fill in if filing Schedule TDS
Married filing jointly
Married filing separate return
Head of household 3
You are a custodial parent who has released claim to exemption for child(ren)
2. Exemptions
4400
a. Personal exemptions
2a
0
b. Number of dependents. (Do not include yourself or your spouse.) Enter number 3
× $1,000 = 2b
0
c. Age 65 or over before 2015
You +
Spouse =
3
× $700 = 2c
0
d. Blindness
You +
Spouse =
3
× $2,200 = 2d
0 2. Adoption 3
0
0
e. 1. Medical/dental 3
1 + 2 = 2e
4400
f. Total exemptions. Add lines 2a through 2e. Enter here and on line 18
3 2f
12291
3. Wages, salaries, tips
33
0
4. Taxable pensions and annuities
34
0 – b. exemption
0
0
5. Mass. bank interest: a. 3
= 5
0
6. Business/profession or farm income or loss
36
0
7. Rental, royalty and REMIC, partnership, S corp., trust income/loss
37
0
8a. Unemployment
3 8a
0
8b. Mass. lottery winnings
3 8b
0
9. Other income from Schedule X, line 5
39
12291
10. TOTAL 5.2% 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 Department of Revenue discuss this return with the preparer shown here? 3
I do not want preparer to file my return electronically
3
Print paid preparer’s name
Paid preparer’s signature
SELF-PREPARED
Yes
(this may delay your refund)
Date
Check if self-employed
3
Paid preparer’s phone
3
PRIVACY ACT NOTICE AVAILABLE UPON REQUEST
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REV 12/11/14 TTO
Paid preparer’s SSN
Paid preparer’s EIN
2014 Form 1, pg. 2 MA1400121555
Massachusetts Resident Income Tax Return
782-04-6455
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
3 11a
Amount your spouse paid to Soc. Sec., Medicare, R.R., U.S. or Mass. Retirement
3 11b
Child under age 13, or disabled dependent/spouse care expenses
3 12
Number of dependent member(s) of household under age 12, or dependents age 65 or over (not you or your spouse) as of
12/31/14, or disabled dependent(s)
× $3,600 = 3 13
Not more than two. a. 3
Rental deduction. a. 3
÷ 2 = 3 14
0
Other deductions from Schedule Y, line 17
3 15
Total deductions. Add lines 11 through 15
3 16
5.2% INCOME AFTER DEDUCTIONS. Subtract line 16 from line 10. Not less than “0”
17
Exemption amount
18
5.2% INCOME AFTER EXEMPTIONS. Subtract line 18 from line 17. Not less than “0”
19
INTEREST AND DIVIDEND INCOME
3 20
TOTAL TAXABLE 5.2% INCOME. Add lines 19 and 20
21
TAX ON 5.2% INCOME. Note: If choosing the optional 5.85% tax rate, fill in and multiply line 21 and the
amount in Schedule D, line 21 by .0585 3
22
12% INCOME. Not less than “0.”
a. 3
× .12 = 23
0
TAX ON LONG-TERM CAPITAL GAINS. Not less than “0.” Fill in if filing Schedule D-IS 3
3 24
Fill in if any excess exemptions were used in calculating lines 20, 23 or 24
3
Credit recapture amount 3
BC
EOA
LIH
HR
3 25
Additional tax on installment sale
3 26
If you qualify for No Tax Status, fill in and enter “0” on line 28
3
TOTAL INCOME TAX. Add lines 22 through 26
28
Limited Income Credit
3 29
Other credits from Schedule Z, line 14
3 30
INCOME TAX AFTER CREDITS. Subtract the total of lines 29 and 30 from line 28. Not less than “0”
31
BE SURE TO INCLUDE THIS PAGE WITH FORM 1, PAGE 1
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REV 12/11/14 TTO
0
0
0
0
0
8927
8927
3364
4400
0
0
0
0
0
0
0
0
0
0
0
0
2014 Form 1, pg. 3 MA1400131555
Massachusetts Resident Income Tax Return
782-04-6455
32. Voluntary Contributions
a. Endangered Wildlife Conservation
b. Organ Transplant Fund
c. Massachusetts AIDS Fund
d. Massachusetts U.S. Olympic Fund
e. Massachusetts Military Family Relief Fund
f. Homeless Animal Prevention and Care
Total. Add lines 32a through 32f
33. Use tax due on Internet, mail order and other out-of-state purchases
34. Health care penalty a. You 3
0 + b. Spouse 3
0 – c. Fed. health care penalty 3
35. INCOME TAX AFTER CREDITS PLUS CONTRIBUTIONS AND USE TAX. Add lines 31 through 34
36. Massachusetts income tax withheld
37. 2013 overpayment applied to your 2014 estimated tax
38. 2014 Massachusetts estimated tax payments
39. Payments made with extension
40. Earned Income Credit. a. Number of qualifying children 3
Amount from U.S. return 3
0
41. Senior Circuit Breaker Credit
42. Other Refundable Credits
43. TOTAL. Add lines 36 through 42
44. Overpayment. Subtract line 35 from line 43
45. Amount of overpayment you want applied to your 2015 estimated tax
46. Refund. Subtract line 45 from line 44. Mail to: Massachusetts DOR, PO Box 7001, Boston, MA 02204
Direct deposit of refund. Type of account
RTN # 3
011000138
account # 3
3
X
0
0
0
0
0
0
0
0
0
0
638
0
0
0
0
0
0
638
638
0
638
3 32a
3 32b
3 32c
3 32d
3 32e
3 32f
32
3 33
0 34
35
3 36
3 37
3 38
3 39
× .15 = 3 40
3 41
3 42
43
3 44
3 45
3 46
checking
savings
004648363011
47. Tax due. Pay online at www.mass.gov/dor/payonline. Mail to: Mass. DOR, PO Box 7002, Boston, MA 02204
Interest 3
0 Penalty 3
0 M-2210 amt. 3
0
BE SURE TO INCLUDE THIS PAGE WITH FORM 1, PAGE 1
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0
3 47
3
EX enclose
Form M-2210
2014 Schedule X & Y MA14SXY11555
ADRIJAN
DELALE
782-04-6455
Schedule X. Other Income
1.
2.
3.
4.
5.
Alimony received
Taxable IRA/Keogh and Roth IRA conversion distributions
Other gambling winnings. Not less than “0.” Gambling losses are not deductible under Massachusetts law
Fees and other 5.2% income. Not less than “0”
Total other 5.2% income. Add lines 1 through 4. Not less than “0”
31
32
33
34
35
0
0
0
0
0
31
32
33
34
0
0
0
0
35
36
37
38
0
0
0
0
39
3 10
3 11
3 12
0
0
8927
0
3 13
3 14
3 15
3 16
3 17
0
0
0
0
8927
Schedule Y. Other Deductions
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Allowable employee business expenses
Penalty on early savings withdrawal
Alimony paid
Amounts excludible under MGL Ch. 41, sec. 111F or U.S. tax treaty incl. in Form 1, line 3 or Form 1-NR/PY, line 5
Income received by a firefighter or police officer incapacitated in the line of duty, per MGL Ch. 41, sec. 111F
Income exempt under U.S. tax treaty
Moving expenses
Medical savings account deduction
Self-employed health insurance deduction
Health care accounts deduction
Certain qualified deductions from U.S. Form 1040
Certain business expenses from U.S. Form 1040
Student loan interest
College Tuition Deduction
Undergraduate student loan interest deduction
Deductible amount of qualified contributory pension income from another state or political subdivision included
in Form 1, line 4 or Form 1-NR/PY, line 6
Claim of right deduction
Commuter deduction
Human organ donation deduction (full-year residents only)
Total other deductions. Add lines 1 through 16
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REV 01/14/15 TTO
2014 Schedule INC MA14INC11555
ADRIJAN
DELALE
782-04-6455
Form W-2 and 1099 Information
A. FEDERAL ID NUMBER
B. STATE TAX WITHHELD
C. STATE WAGES/INCOME
D. TAXPAYER SS WITHHELD
E. SPOUSE SS WITHHELD
20-8849819
20-4936172
384
254
7378
4913
0
0
0
0
TOTALS
638
12291
0
0
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F. SOURCE OF WITHHOLDING
W2
W2
2014 Schedule HC MA1402911555
Schedule HC, Health Care Information, must be completed by all
full-year residents and certain part-year residents (see instructions).
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.
ADRIJAN
1a. Date of birth
DELALE
3
10141992
782-04-6455
1b. Spouse’s date of birth 3
1
1c. Family size 3
2. Federal adjusted gross income
32
12291
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, 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.
See instructions if, during 2014, you turned 18, you
3 3a You:
Full-year MCC
were a part-year resident or a taxpayer was deceased.
Full-year MCC
3 3b Spouse:
If you filled in the full-year or part-year MCC oval, go to line 4. If you filled in No MCC/None, go to line 6.
X
Part-year MCC
Part-year MCC
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 2014, 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 or Commonwealth Care 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 ConnectorCare. Fill in and go to line 5
You
Spouse
You
Spouse
4c. Medicare (including a replacement or supplemental plan). Fill in and go to line 5
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 Safety Net
You
Spouse
is not considered insurance or minimum creditable coverage.
4f.
4g.
X
60-0540315
Your Health Insurance. Complete if you answered line(s) 4a or 4e and go to line 5.
AETNA STUDENT HEALTH
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.
1281035030
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 or Commonwealth Care, 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 2014, you are not subject to a penalty. Skip the remainder of this schedule and continue completing your tax return. Otherwise, go to line 6.
04/15/2015 12:13 PM
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2014 Schedule HC, pg. 2
782-04-6455 MA1402921555
Uninsured for All or Part of 2014
X Yes
6. Was your income in 2014 at or below 150% of the federal poverty level?
No
36
If you answer Yes, you are not subject to a penalty in 2014. Skip the remainder of this schedule and complete your tax return. If you answer No and you were enrolled
in a health insurance plan that met the MCC requirements for part, but not all, of 2014, go to line 7. If you answer No and you had no insurance or you were enrolled in
a plan that did not meet the MCC requirements during the period that the mandate applied, go to line 8a.
7. Complete this section only if you, and/or your spouse if married filing jointly, were enrolled in a health insurance plan(s) that met the Minimum Creditable
Coverage (MCC) requirements for part, but not all of 2014. Fill in below the months that met the MCC requirements, as shown on Form MA 1099-HC. If you
did not receive this form, fill in the months you were covered by a plan that met the MCC requirements at least 15 days or more. If, during 2014, you turned
18, you were a part-year resident or a taxpayer was deceased, fill in the oval(s) below for the month(s) that met the MCC requirements during the period
that the mandate applied. See instructions.
You may only fill in the month(s) you had health insurance that met MCC requirements. If you had health insurance, but it did not meet MCC requirements,
you must skip this section and go to line 8a.
Months Covered By Health Insurance
You
Spouse
Jan.
Jan.
Feb.
Feb.
March
March
April
April
May
May
June
June
July
July
Aug.
Aug.
Sept.
Sept.
Oct.
Oct.
Nov.
Nov.
Dec.
Dec.
If you had four or more consecutive months either with no insurance or insurance that did not meet the MCC requirements (four or more blank months in a row),
go to line 8a. Otherwise, a penalty does not apply to you in 2014. Skip the remainder of this schedule and complete your tax return.
Religious Exemption and Certificate of Exemption
8a. Religious exemption: Are you claiming an exemption from the requirement to purchase health insurance based
on your sincerely held religious beliefs that cause you to object to substantially all forms of treatment covered by
health insurance?
If you answer Yes, go to line 8b. If you answer No, go to line 9.
8b. If you are claiming a religious exemption in line 8a, did you receive medical health care during the 2014 tax year?
3 8a You
Yes
No
Spouse
Yes
No
Yes
Spouse
Yes
If you answer No to line 8b, skip the remainder of this schedule and continue completing your tax return. If you answer Yes to line 8b, go to line 9.
9. Certificate of exemption: Have you obtained a Certificate of Exemption issued by the Commonwealth Health
3 9 You
Yes
Insurance Connector Authority for the 2014 tax year?
Spouse
Yes
If you answer Yes, enter the certificate number, skip the remainder of this schedule and continue completing your tax
return. If you answer No to line 9, go to line 10.
No
No
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REV 12/12/14 TTO
3 8b You
No
No
2014 Schedule HC, pg. 3
MA1402931555
ADRIJAN
DELALE
782-04-6455
Affordability as Determined By State Guidelines
Note: This section will require the use of worksheets and tables found in the instructions. You must complete the worksheet(s) to determine if health insurance was
affordable to you during the 2014 tax year.
10. Did your employer offer affordable health insurance that met minimum creditable coverage requirements
3 10 You
Yes
No
as determined by completing the Schedule HC Worksheet for Line 10 in the instructions?
Spouse
Yes
No
Fill in No if your employer did not offer health insurance that met minimum creditable coverage requirements, you were not eligible for health insurance offered by
your employer, you were self-employed or you were unemployed.
11. Were you eligible for government-subsidized health insurance as determined by completing the Schedule HC
3 11 You
Yes
No
Yes
No
Worksheet for Line 11 in the instructions?
Spouse
If you answer No, go to line 12. If you answer Yes, go to the Health Care Penalty Worksheet in the instructions to calculate your penalty amount.
12. Were you able to purchase affordable private health insurance that met minimum creditable coverage requirements
3 12 You
Yes
No
Yes
No
as determined by completing the Schedule HC Worksheet for Line 12 in the instructions?
Spouse
If you answer No, you are not subject to a penalty. Continue completing your tax return. If you answer Yes, go to the Health Care Penalty Worksheet in the
instructions to calculate your penalty amount.
Complete Only If You Are Filing An Appeal
You must complete the Health Care Penalty Worksheet to determine your penalty amount before completing this section.
You may have grounds to appeal if you were unable to obtain affordable insurance that meets the minimum creditable coverage requirements in 2014 due to a
hardship or other circumstances. The grounds for appeal are explained in more detail in the instructions. If you believe you have grounds for appealing the penalty, fill
in the field(s) below. The appeal will be heard by the Commonwealth Health Insurance Connector Authority. By filling in the field below, you (or your spouse if married
filing jointly) are authorizing DOR to share information from your tax return, including this schedule, with the Connector Authority for purposes of deciding your appeal.
You will receive a follow-up letter asking you to state your grounds for appeal in writing, and submit supporting documentation. Failure to respond to that
letter within the time specified in the letter will lead to dismissal of your appeal and will result in a future assessment of a penalty. Once your documentation is received, it will be reviewed by the Commonwealth Health Insurance Connector Authority and you may be required to attend a hearing on your case. You will
be required to file your claims under the pains and penalties of perjury.
Note: If you are filing an appeal, make sure you have calculated the penalty amount that you are appealing, but do not assess yourself or enter a penalty amount on
your Form 1 or Form 1-NR/PY. Also, do not include any hardship documentation with your original return. You will be required to submit substantiating hardship
documentation at a later date during the appeal process.
You
I wish to appeal the penalty. I authorize DOR to share this tax return including this schedule with the Commonwealth Health Insurance
Connector Authority for purposes of deciding this appeal.
Spouse
I wish to appeal the penalty. I authorize DOR to share this tax return including this schedule with the Commonwealth Health Insurance
Connector Authority for purposes of deciding this appeal.
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REV 12/12/14 TTO
Schedule HC
Worksheet
Adrijan's Schedule HC Worksheet
2014
G Keep for your records
Name(s) Shown on Return
Social Security Number
Adrijan Delale
782-04-6455
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. (See the special section on MCC requirements in the instructions.)
Full-year MCC
X Part-year MCC
No MCC/None
4
Indicate the health insurance plan(s) that met the Minimum Creditable Coverage (MCC) requirements
in which you were enrolled in 2014, as shown on Form MA 1099-HC (check all that apply). If you
did not receive this form, check line(s) 4f and/or 4g and see instructions. Check if you were enrolled in
private insurance and MassHealth or Commonwealth Care, and enter your private insurance
information in Your Health Insurance Smartworksheet.
Private Insurance (complete Your Health Insurance Smart Worksheet below)
You X
MassHealth, Commonwealth Care or ConnectorCare
You
Medicare
You
U.S. Military (including Veterans Administration and Tri-Care)
You
Other government program (enter the program name(s) only below
You
a
b
c
d
e
Name of Insurance Carrier or Program
4f
Check if you were not issued Form MA 1099-HC
X
Your Health Insurance Smart Worksheet
7
Name of Insurance Company or Administrator
(from Form MA 1099-HC)
Federal Identification No. of
Insurance Company (from
Form MA 1099-HC)
Subscriber No. (from
Form MA 1099-HC)
AETNA STUDENT HEALTH
60-0540315
1281035030
Complete this section only if you and/or your spouse if MFJ, were enrolled in a health insurance
plan(s) that met the Minimum Creditable Coverage (MCC) requirements for part, but not all of 2014.
Check the months that met the MCC requirements, as shown on Form MA 1099-HC. If you did not
receive this form, check the months you were covered by a plan that met the MCC requirements at
least 15 days or more. See instructions if, during 2014, you turned 18, you were a part-year
resident or a taxpayer was deceased.
Special Circumstance Instructions
Indicates special circumstances
Check the month(s) you were alive, age 18, or a resident of Massachusetts for 2014
Jan
Feb
March
April
May
July
Aug
Sept
Oct
Nov
June
Dec
Months Covered By Health Insurance That Met Minimum Creditable Coverage
You should only check the month(s) you had health insurance that met MCC requirements.
Jan
Feb
March
April
X May
X
X July
X Aug
X Sept
X Oct
Nov
June
Dec
Adrijan Delale
782-04-6455
Page 2
Religious Exemption and Certificate of Exemption
8 a Religious exemption: Are you claiming an exemption from the
requirement to purchase health insurance based on your sincerely
held religious beliefs that cause you to object to substantially all
forms of treatment covered by health insurance?
Yes
No
If you answer Yes, go to line 8b. If you answer No, go to line 9.
8 b If you are claiming a religious exemption in line 8a, did you
receive medical health care during the 2014 tax year?
Yes
No
Yes
No
If you answer No to line 8b, skip the remainder of this schedule and
continue completing your tax return. If you answer Yes to line 8b, go
to line 9.
9
Certificate of exemption: Have you obtained a Certificate of
Exemption issued by the Commonwealth Health Insurance
Connector Authority for the 2014 tax year?
If you answer Yes enter the certificate number, skip the remainder of
this schedule and continue completing your tax return. If you answer
No to line 9, go to line 10.
Certificate No.
Schedule HC Worksheet for Line 10
Did your employer (or your spouse’s employer if married filing jointly) offer
you health insurance?
If you answered "Yes" above, was this insurance free?
Yes
Yes
The following worksheet will determine if you could have afforded employer-sponsored health insurance that
met Minimum Creditable Coverage in 2014. Complete only if you (and/or your spouse if married filing
jointly) were eligible for insurance that met Minimum Creditable Coverage offered by an employer for the
entire period you were uninsured in 2014 that covered you, and your spouse and dependent children, if
any. If an employer did not offer health insurance that met Minimum Creditable Coverage that covered you,
and your spouse and dependent children, if any, or if you were not eligible for insurance that met Minimum
Creditable Coverage offered by an employer, you were self employed or you were unemployed, check the
No box on line 10 and complete the Schedule HC Worksheet for line 11.
Note: If line 6 of the Schedule HC is checked Yes indicating that your income was at or below 150% of the
federal poverty level or you had three or fewer blanks in a row during the period that the
mandate applied on line 7 of Schedule HC, the penalty does not apply to you. Do not complete this
worksheet. If an employer offered you free health insurance coverage in 2014 that met Minimum Creditable
Coverage (the employer’s Human Resources Department should be able to provide this information to you),
you are deemed able to afford health insurance and are subject to a penalty. Check the Yes box in line 10
and go to the Health Care Penalty Worksheet.
1
Enter your federal adjusted gross income (from U.S. Form 1040, line 37, Form
1040A, line 21 or Form 1040EZ, line 4)
1
If line 1 is less than or equal to:
G $17,508 if single or married filing a separate with no dependents;
G $23,604 if married filing jointly with no dependents or head of household/married filing
separately with one dependent; or
G $29,688 if married filing jointly with one or more dependents or head of household/married
filing separately with two or more dependents,
you are deemed unable to afford employer-sponsored health insurance that met Minimum Creditable
Coverage requiring an employee contribtuion. Check the No box in line 10. Skip the remainder of this
worksheet and go to the Schedule HC Worksheet for Line 11.
No
No
Adrijan Delale
782-04-6455
Page 3
If line 1 is more than:
G $17,508 if single or married filing separately with no dependents;
G $23,604 if married filing jointly with no dependents or head of household/married filing
separately with one dependent; or
G $29,688 if married filing jointly with one or more dependents or head of household/married
filing separately with two or more dependents, go to line 2.
2
Enter the lowest monthly premium cost of health insurance that would cover
you, and your spouse and dependent children, if any, offered to you during
your uninsured period in 2014 through an employer. The employer’s Human
Resources Department should be able to provide this amount to you
2
Note: If you declined employer-sponsored health insurance that met the Minimum Creditable Coverage, the
monthly premium amount may be found on the Health Insurance Responsibility Disclosure Form (HIRD) you
should have received from your employer.
If line 1 is more than:
G $17,508 but less than or equal to $46,680 if single or married filing separately with no dependents;
G $23,604 but less than or equal to 62,928 if married filing jointly with no dependents or head of
household/married filing separately with one dependent; or
G $29,688 but less than or equal to $79,164 if married filing jointly with one or more dependents or
head of household/married filing separately with two or more dependents, go to line 3.
If line 1 is more than:
G $46,680 if single or married filing separately with no dependents;
G $62,928 if married filing jointly with no dependents or head of household/married filing separately with
one dependent; or
G $79,164 if married filing jointly with one or more dependents or head of household/married filing
separately with two or more dependents, skip line 3 and go to line 4.
3
Enter the monthly premium that corresponds with your income range (from line
1 above) and filing status from Table 3 in the instructions
3
If line 2 is less than or equal to line 3, you are deemed able to afford employer-sponsored health insurance
that met Minimum Creditable Coverage during your uninsured period(s), which you did not obtain, and
G you are subject to a penalty. Check the Yes box in line 10 and
G go to the Health Care Penalty Worksheet.
If line 2 is greater than line 3: you could not afford health insurance that met Minimum Creditable Coverage
offered to you by your employer, check
G the No box in line 10 and
G complete the Schedule HC Worksheet for Line 11.
4 Divide line 1 by 150
4
If line 2 is less than or equal to line 4: you are deemed able to afford employer-sponsored health insurance
that met Minimum Creditable Coverage during your uninsured period(s), which you did not obtain, and you
are subject to a penalty.Check the Yes box in line 10, and go to the Health Care Penalty Worksheet below.
If line 2 is greater than line 4: you could not afford health insurance that met Minimum Creditable Coverage
offered to you by your employer, check the No box in line 10, and complete the following Schedule HC
Worksheet for line 11.
Adrijan Delale
782-04-6455
Page 4
Schedule HC Worksheet for Line 11: Eligibility for Government-Subsidized Health Insurance
Line 11: Eligibility for Government-Subsidized Health Insurance Smart Worksheet
A In 2014, were any of these statements true?
G I was not a citizen or an alien legally residing in the U.S.,
G An employer offered an individual plan that cost less than 9.5% of your household income
and met minimum value standards (the employer’s Human Resource Department should be
able to provide this information to you),
G I applied for Mass Health or subsidized coverage through the Health Connector and were
denied because I was inelegible for services,
Are any of the statements in A true?
No
Yes
The following worksheet will determine if you were eligible for government-subsidized health insurance in
2014. Complete the following worksheet only if an employer did not offer you affordable health insurance
that met Minimum Creditable Coverage requirements, as determined in the Schedule HC Worksheet for
Line 10.
Note: If line 6 of the Schedule HC is checked Yes indicating that your income was at or below 150%
of the Federal Poverty Level or you had three or fewer blanks in a row on line 7 of Schedule HC, the
penalty does not apply to you. Do not complete this worksheet. Skip the remainder of Schedule HC and
continue completing your return.
If married filing separately and living in the same household, each spouse must combine their income
figures from their separate U.S. returns when completing this worksheet.
1
2
Enter your federal adjusted gross income (from U.S. Form 1040, line 37, Form
1040A, line 21 or Form 1040EZ, line 4)
Enter the amount from the Income column, based on your family size (do not
include dependent children age 19 or older in your family size), from Table 2
in the instructions
1
2
34470
If line 1 is greater than line 2:
G you were ineligible for government-subsidized health insurance in 2014 and must
G check the No box in line 11, and
G go to Schedule HC Worksheet for line 12 to determine if you were deemed able to afford private health
insurance.
If line 1 is less than or equal to line 2, and at any point during the period when you were uninsured:
G you were not a citizen or an alien legally residing in the U.S., or
G an employer offered an individual plan that cost less than 9.5% of your household income (the
employer’s Human Resources Department should be able to provide this information to you) or
G you applied for Mass Health or subsidized coverage through the Health Connector and were denied
because you were ineligible for services,
you are deemed ineligible for government-subsidized health insurance in 2014 and must
G check the No box in line 11, and
G go to Schedule HC Worksheet for line 12 to determine if you were deemed able to afford private health
insurance.
If line 1 is less than or equal to line 2 and none of the conditions above apply, then
G you would have been deemed eligible for government-subsidized health insurance in 2014 which you
did not obtain and you are subject to a penalty. You must
G check the Yes box in line 11, and go to the Health Care Penalty Worksheet.
Note: If you believe that during the period when you were unisured, your income was actually too high to
qualify for government-subsidized insurance, you may have grounds to appeal the penalty. Check the Yes
box in line 11 and go to the instructions for the Appeals section on schedule HC.
Adrijan Delale
782-04-6455
Page 5
Schedule HC Worksheet for Line 12: Ability to Purchase Affordable Private Health Insurance That
Met Minimum Creditable Coverage
The following worksheet will determine if you could have purchased affordable private health insurance that
met Minimum Creditable Coverage in 2014. Complete the following worksheet only if you (and/or your
spouse if married filing jointly) were deemed ineligible for government-subsidized health insurance, as
determined in the Schedule HC Worksheet for Line 11.
Note: If line 6 of the Schedule HC is checked Yes indicating that your income was at or below
150% of the Federal Poverty Level or you had three or fewer blanks in a row on line 7 of Schedule HC, the
penalty does not apply to you. Do not complete this worksheet. Skip the remainder of Schedule HC and
continue completing your return. Schedule HC must be attached to your return.
1
2
Enter your federal adjusted gross income (from U.S. Form 1040, line 37, Form
1040A, line 21 or Form 1040EZ,
line 4)
Enter the monthly premium that corresponds with your county of residency
(see the printed government instructions if you do not know what county you
live in), age (if married filing a joint return, use the age of the older spouse)
and filing status from Table 4: Premiums.
Look at the table that corresponds to your county of residency and go to the
row for your age range and then go to the column based on your filing status
to find the monthly premium amount
1
2
If line 1 is less than or equal to:
G $46,680 if single or married filing separately with no dependents;
G $62,928 if married filing jointly with no dependents or head of household/married filing separately with
one dependent; or
G $79,164 if married filing jointly with one or more dependents or head of household/married filing
separately with two or more dependents, go to line 3.
If line 1 is more than:
G $46,680 if single or married filing separately with no dependents;
G $62,928 if married filing jointly with no dependents or head of household/married filing separately with
one dependent; or
G $79,164 if married filing jointly with one or more dependents or head of household/married filing
separately with two or more dependents, skip line 3 and go to line 4.
3
Enter the monthly premium that corresponds with your income range (from
line 1 of worksheet) and filing status from Table 3: Affordability. To find this
amount, look at the row for your income range in column a of the appropriate
table based on your filing status and go to column b to find the monthly
premium amount
3
If line 2 is greater than line 3:
G you are deemed unable to afford health insurance that met Minimum Creditable Coverage and not
subject to a penalty,and you must
G check the No box in line 12 and
G skip the remainder of Schedule HC and continue completing your tax return. Be sure to enclose the
Schedule HC with your return
Adrijan Delale
782-04-6455
Page 6
If line 2 is less than or equal to line 3, and at any point during the period when you were uninsured:
G you were 18 years or older and were offered insurance that met Minimum Creditable Coverage through
an employer, or
G you are deemed ineligible to purchase private health insurance in 2014
G check the No box in line 12 and
G skip the remainder of Schedule HC and continue completing your tax return. Be sure to enclose the
Schedule HC with your return
If line 2 is less than or equal to line 3 and none of the above conditions apply:
G you are deemed able to afford private health insurance that met Minimum Creditable Coverage, which
you did not obtain;
G you are subject to a penalty and you must
G check the Yes box in line 12 and go to the Health Care Penalty Worksheet.
4
Divide line 1 by 150
4
If line 2 is greater than line 4:
G you are deemed unable to afford health insurance that met Minimum Creditable Coverage and not
subject to a penalty,and you must
G check the No box in line 12 and
G skip the remainder of Schedule HC and continue completing your tax return.
If line 2 is less than or equal to line 4, and at any point during the period when you were uninsured:
G you were 18 years or older and were offered insurance that met Minimum Creditable Coverage through
an employer, or
G you are deemed ineligible to purchase private health insurance in 2014
G check the No box in line 12 and
G skip the remainder of Schedule HC and continue completing your tax return. Be sure to enclose the
Schedule HC with your return
If line 2 is less than or equal to line 4 and none of the above conditions apply:
G you are deemed able to afford private health insurance that met Minimum Creditable Coverage, which
you did not obtain;
G you are subject to a penalty and you must
G check the Yes box in line 12 and go to the Health Care Penalty Worksheet.
Schedule HC Worksheet - Penalty Worksheet
Complete the following worksheet to calculate the penalty. If married filing a joint return and both you and
your spouse are subject to a penalty, separate worksheets must be filled out to calculate the separate
penalty amounts for you and your spouse, using your married filing jointly income. Each separate penalty
amount must then be entered on Form 1, line 34a and line 34b or Form 1-NR/PY, line 39a and line 39b.
Note: If line 6 is checked of the Schedule HC is checked Yes indicating that your income was at or below
150% of the Federal Poverty Level, the penalty does not apply to you. Do not complete this worksheet. Skip
the remainder of Schedule HC and continue completing your return.
1
3
Enter your federal adjusted gross income from line 2 of Schedule HC
Based on Family Size, federal AGI and your age
calculated penalty
4
How many gap(s) in coverage of four or more consececutive months do you
have in Schedule HC, line 7? If you were uninsured for all of 2014 enter "0"
G Turning 18, Part-Year Residents or a Taxpayer was deceased . When
completing line 4, do not include the number of unfilled checkboxes for months
that the mandate did not apply, as determined in Schedule HC, line 7.
5
Enter the total number of months for the gap(s) in coverage as identified in
line 4. Enter "12" if you were uninsured for all of 2014.
G ATTENTION: Taxpayer, or Spouse if married filing jointly, was deceased or
Turned 18 or a Part-Year Resident. See Government Instructions Sch. HC.
6
Multiply line 4 by "3"
7
Subtract line 6 from line 5. This is the number of months subject to
the penalty
8
Multiply line 3 by line 7. This is the penalty amount for you
1
3
4
1
5
12
6
3
7
8
9
0
If you are subject to a penalty because you are deemed able to afford insurance in 2014 but did not obtain it, you may appeal
the application of the penalty to you. Go to the Filing an Appeal section on the Schedule HC and follow these instructions.
If you are filing an appeal, do not enter a penalty amount on Form 1, line 34a or line 34b or Form 1-NR/PY, line 39a and
line 39b. If you are not appealing the penalty, enter the penalty amount from line 8 on Form 1, line 34a or 34b or
Form 1-NR/PY, line 39a and line 39b.
Complete Only If You Are Filing An Appeal
You:
I wish to appeal the penalty. I authorize DOR to share my tax return including this schedule
with the Commonwealth Health Insurance Connector Authority for purposes of deciding
my appeal.
maiw0601.SCR 03/10/15