Fillable Form 200 - Local Intangibles Tax Return

200

LOCAL INTANGIBLES TAX RETURN

2015

(Rev. 8/14)

For tax year January 1 - December 31, 2014, or other taxable year beginning ______________ , 20_____ ; ending ______________ , 20_____

First Name (If joint return, use first names and middle initials of both)

Last Name

Your Social Security Number

–

Spouse’s Social Security Number

Mailing Address (Number and street, including apartment number, or rural route)

–

City, Town, or Post Office, State and Zip Code

Federal Identification Number

For County Use Only

Questions 1 & 2 must be answered before your intangibles tax rate can be determined.

TAX UNIT NUMBER

1. Is your legal residence located within the corporate limits of a city or town?

‰

Yes. If yes, name of city or town: _______________________________________________________

‰

No. If no, name of township: ___________________________________________________________

2. County of residence as of January 1, 2015: __________________________________________________

3. Intangibles income (from line 11, Part 1 or line 17, Part II)

$ ___________________________

YOUR COUNTY CLERK WILL COMPUTE YOUR INTANGIBLES TAX LIABILITY. YOUR COUNTY TREASURER WILL BILL YOU.

DO NOT SEND ANY PAYMENT FOR INTANGIBLES TAX TO THE KANSAS DEPARTMENT OF REVENUE.

PART I – INTANGIBLES EARNINGS

4. Interest from bank savings accounts, certificates of deposit, other time deposits, insurance companies, and interest

or dividends received from all savings and loan associations and credit unions .........................................................

5. Dividends or other income from corporation stock including those located in Kansas and dividends or interest

income received from mutual funds and trust companies .............................................................................................

6. Interest from notes (except when secured by mortgages on Kansas real estate when registration fee has been paid)

7. Earnings from conditional sales contracts, chattel paper, or other secured transactions ...........................................

8. Interest or discount income from bonds, debentures, and certificates of indebtedness .............................................

9. Interest carrying charges and other income from accounts receivable (nonresidents: see instructions) ...................

10. Other intangibles income (see instructions) ...................................................................................................................

11. Total intangibles income. If you qualify for the “Special Senior Citizen or Disability Exemption” complete Part II

to determine your intangibles income. If you do not qualify for the exemption, enter this amount on line 3. ............

PART II – SPECIAL SENIOR CITIZEN OR DISABILITY EXEMPTION – see instructions

(Part II must be completed entirely or the exemption will not be allowed)

MONTH

DAY

YEAR

12. Your date of birth. If you were born after January 1, 1954, you must be blind or

disabled to qualify (see instructions) .................................................................................

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13. Is this special exemption based on disability or blindness? If yes, attach proof of disability or blindness (see instructions).

Yes

14. Total household income for 2014 (must be less than $20,000; see instructions) ........................................................

15. Enter total intangibles income from Part I, line 11 .........................................................................................................

16. LESS: Special intangibles income exemption (see instructions for allowable exemption) ..........................................

17. Taxable intangibles income (subtract line 16 from line 15; enter result here and on line 3 above) .........................

I declare under the penalties of perjury that to the best of my knowledge and belief, this is a true, correct, and complete return.

_____________________________________________________________

_________________________________________________

sign

Signature of taxpayer

Date

here

_____________________________________________________________

_________________________________________________

If joint return, BOTH husband and wife must sign