Form 511 - Oklahoma Resident Individual Income Tax Forms And Instructions - 2014 Page 39

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State of Oklahoma

Claim for Credit/Refund of Sales Tax

538 S

Taxpayer Social

If died in 2014 or 2015,

Instructions on page 2.

Security Number

enter date of death:

Please read carefully as

an incomplete form may

If died in 2014 or 2015,

Spouse’s Social

delay your refund.

enter date of death:

Security Number

Part 1: Taxpayer Information

Taxpayer first name, middle initial and last name

Physical address in 2014 (if different than shown in mailing address section)

Spouse’s first name, middle initial and last name (if a joint return)

Place an ‘X’ if you or your spouse have a physical disability

constituting a substantial handicap to employment (submit proof)

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

Place an ‘X’ if you or your spouse are 65 years of age or over

City, State and ZIP

Oklahoma resident for the entire year?

yes

Exemption Information

Part 2: Dependent

Note: Do not enter the taxpayer or spouse as a dependent.

Qualified Exemptions...

1. Dependents

See Instructions

5.Yearly

A. Yourself ............................

(first name, middle initial, last name) If you have

2. Age 3. Social Security Number

4. Relationship

Income

additional dependents, please attach schedule.

B. Spouse .............................

C. Number of your

dependent children...

D. Number of other

dependents ..............

E. Total exemptions

claimed (add A-D) ....

Part 3: Gross Income:

Enter taxable and nontaxable gross income and assistance received by ALL members of your household in the year 2014.

Yearly Income

See “Total gross household income” definition on page 2 for examples of income.

You may not enter negative amounts.

1. Enter total wages, salaries, fees, commissions, bonuses, and tips

(including nontaxable income from your W-2s) ......................................................................

2. Enter total interest and dividend income received ...................................................................

3. Total of all dependents’ income (from Part 2, column 5) ..........................................................

4. Social Security payments (total including Medicare) ...............................................................

5. Railroad Retirement benefits ...................................................................................................

6. Other pensions, annuities and IRAs ........................................................................................

7. Alimony ....................................................................................................................................

8. Unemployment benefits ...........................................................................................................

9. Earned Income Credit (EIC) received in 2014..........................................................................

10. Nontaxable sources of income (specify) _________________________________ ..............

You may not enter negative amounts.

11. Enter gross (positive) income from rentals, royalties, partnerships, estates & trusts, and gains

from the sale or exchange of property

.......

(taxable & nontaxable) (enclose Federal return including schedules)

12. Enter gross (positive) income from business and farm

.........

(enclose Federal return including schedules)

13. Other income-including income of others living in your household (specify) _____________

14. Total gross household income (Add lines 1-13) ...................................................................

If line 14 is over income limits shown in steps 2 and 3 on back of this form, no credit is allowed.

Part 4: Sales Tax Credit Computation

(For households with gross income below allowable limits, see steps 2 and 3 on back of form.)

15. Total qualified exemptions claimed in Box E above

x $40 (credit claimed) ..........

For those NOT filing a Form 511.

Direct Deposit Option:

If you are filing a Form 511, carry the credit to Form 511, line 26.

See page 2 for Refund Information.

Deposit my refund in my:

Routing

Is this refund going to or through an

Number:

account that is located outside of

checking account

the United States?

Account

savings account

Yes

Number:

If the Oklahoma Tax Commission may discuss this return

Under penalty of perjury, I declare the information contained in this document and any attachments is true and correct to the best of my knowledge and belief.

with your tax preparer, place an ‘X’ here:

Taxpayer’s Signature and Date

Spouse’s Signature and Date

Preparer’s Signature and Date

Occupation