Form Sf - 1040r - Individual Return Due - 2009 Page 2
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3EXEMPTIONS & DEPENDENTS SCHEDULE
Perm. Disabled
Para-/Hemi-
Regular
65 & over
Blind
Deaf
Quadriplegic
Date of Birth
You
Box A
Box A - Number of
Spouse
boxes checked
First Name
Last Name
Social Security Number
Relationship
Date of Birth
Box B - Number of Box B
dependents you
claimed on your
federal return
(list to the left)
Box C -Total
Box C
exemptions.
(Box A and B)
SCHEDULE SF-W2 - FOR FORM SF-1040 LINE 1
Total wages
Check here if for spouse
Total wages
Check here if for spouse
EMPLOYER 1
EMPLOYER 4
( W-2, box 1)
(W-2, box 1)
Employer's
Employer's
name
name
Address of actual
Address of actual
work station
work station
Dates of
From
To
Dates of
From
To
employment
employment
Check here if for spouse
Check here if for spouse
EMPLOYER 2
EMPLOYER 5
Employer's
Employer's
name
name
Address of actual
Address of actual
work station
work station
Dates of
Dates o
f
From
From
To
To
Dates of
Dates o
f
From
From
To
To
employment
employment
Check here if for spouse
Check here if for spouse
EMPLOYER 3
EMPLOYER 6
Employer's
Employer's
name
name
Address of actual
Address of actual
work station
work station
Dates of
From
To
Dates of
From
To
employment
employment
TO PAY BY CREDIT CARD FILL IN BELOW
ELECTRONIC FUNDS WITHDRAWAL (SEE BOTTOM OF PG 7)
Master Card
Visa
Total $
Card Number:
Exp. Date:
Signature:
Month
Year
THIRD PARTY DESIGNEE
Do you want to allow another person to discuss this return with the Income Tax Department?
Yes
No If yes, complete the following:
Designee's
Phone
Personal Identification
Name
No.
Number (PIN)
PLEASE SIGN YOUR RETURN BELOW
If joint return, both husband and wife must sign.
I declare that I have examined this return (including accompanying schedules and statements) and to the best of my knowledge and belief it is true, correct and complete.
If prepared by a person other than taxpayer, the preparer's declaration is based on all information of which he/she has any knowledge.
Date
Date
====>
x
X
SIGN
SIGNATURE OF PREPARER OTHER THAN TAXPAYER
TAXPAYER'S SIGNATURE
Phone #
HERE
Occupation:
====>
Date
SPOUSE'S SIGNATURE
PREPARER'S ADDRESS
X
Occupation
PREPARER'S PHONE NUMBER:
: CITY OF SPRINGFIELD
MAKE CHECK OR MONEY ORDER PAYABLE TO
MAIL TO: SPRINGFIELD INCOME TAX DEPARTMENT, 601 AVENUE A, SPRINGFIELD, MI 49037-7774
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