2011 Income Tax Return

Kansas Return
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K-40 2011
DORA L MORA 720 S EDGEMOOR WICHITA X
Amended Return:

KANSAS INDIVIDUAL INCOME TAX FOOD SALES TAX REFUND

006

122811

3162145839 KS 67218 WH 259

MORA

931774471

Filing Status:

Residency Status:

Exemptions:

Single

4 1 5

List below dependent name(s), date of birth, relationship, and SSN of persons claimed. Enclose additional sheets if needed.

KS 05261992 08201931 07171999 DAUGHTER PARENT NIECE 931774467 981701467 926864374

MARTHA A ROSAS DELIA ROQUE VALERIA GUTIERREZ

Food Sales Tax Qualification: If you were a Kansas resident for all 2011, complete lines A through E to determine if you qualify for a Food Sales Tax refund.

A.

D.

B. E.

C.

FOOD SALES TAX REFUND.

IMPORTANT:

K-40 2011
(Rev. 6/11) Page 2

KANSAS INDIVIDUAL INCOME TAX and/or FOOD SALES TAX REFUND 931774471 -10798 0 -10798 4500 11250 15750 0 0
21. Estimated tax paid

006

122911

DORA L MORA
1. Federal adjusted gross income

0 0 0 0

2. Modifications

22. Amount paid with KS extension

3. Kansas adjusted gross income

23. Earned income credit

4. Standard or itemized deductions

24. Refundable portion of tax credits

5. Exemption allowance

25. Payments remitted w/ original return

6. Total deductions

26. Overpayment from original return 27. Total refundable credits and if applicable your Food Sales Tax refund.

7. Taxable income

8. Tax

28. Underpayment

9. Nonresident percentage

29. Interest

10. Nonresident tax

30. Penalty

11. KS tax on lump sum distributions

31. Estimated tax penalty

12. TOTAL INCOME TAX

0 0 0 0 0 0 0 0 0

32. AMOUNT YOU OWE

0 0 0 0 0 0 0 0

13. Credit for taxes paid to other states

33. Overpayment

14. Credit for child & dependent care exp.

34. CREDIT FORWARD

15. Other credits

35. Chickadee Checkoff

16. Total tax credits

36. Senior Citizens Meals On Wheels Contribution Program 37. Breast Cancer Research Fund

17. Income tax balance after credits

18. Use Tax Due

38. Military Emergency Relief Fund

19. Total Tax Balance 20. KS income tax withheld from W-2, 1099 or K-19

39. REFUND

I authorize the Director of Taxation or the Director's designee to discuss my K-40 and any enclosures with my preparer. I declare under the penalties of perjury that to the best of my knowledge and belief this is a true, correct, and complete return.
Taxpayer Signature (Required) Spouse Signature (Required) Preparer Date Signature

Preparer PTIN, EIN, or SSN

Preparer Date Phone Number

K-40H
(Rev. 6/11)

2011

KANSAS HOMESTEAD CLAIM

MORA WH X
Name or address has changed?

006

135011 931774471 3162145839

Filing an amended claim

DORA L MORA 720 S EDGEMOOR WICHITA KS 67218

Claimant died during 2011 --- Date of death

1. Age 55 or over for the entire year. Enter date of birth

7. Railroad Retirement benefits & all other pensions, annuities, & veterans benefits (do not include disability payments from Veterans and Railroad Retirement) 8. TAF payments, general assistance, worker's compensation, grants and scholarships

2. Disabled or blind for the entire year. Enter date disability began. 3. Enter date of birth of dependent Child's name __________________ _____________________________________

VALERIA GUTIERREZ

07171999

9. All other income, including income of others who resided with you at any time during 2011 10. TOTAL HOUSEHOLD INCOME

Check if filing as surviving spouse of a disabled veteran OR an active duty service member who died in the line of duty. 4a. 2011 Wages OR KAGI $

11. OWNER - 2011 general property taxes

980

4b. Federal Earned Income Credit.

Check if you have delinquent property taxes.

4c. Enter the total. Add lines 4a and 4b. 5. All taxable income other than wages/pensions not included in Line 4. Do not subtract net operating/capital losses. 6. Total SS & SSI benefits incl. Medicare deductions, received in 2011 (do not include disability payments from SS or SSI). $______________ Enter 50% of this total.

12. RENTER

13. Total

700 100 700

14. Enter your refund percentage

15. Homestead refund

NOTE: If you filed Form K-40PT for 2011, you DO NOT qualify for this refund.
(a) Food stamps (d) Settlements (g) Other: Source

IMPORTANT: If you filed Form ELG with your county, your refund will be reduced by the ELG amount applied to the first half of your 2011 property tax.
(c) Child support (f) SSI, Social Security, Verterans or Railroad Disability Amount

Excluded Income - Providing the information should speed up the processing of your claim. Enter the annual amount of all other income not included as income on line 10. (b) Nongovernmental Gifts (e) Personal and Student Loans

Owner Statement - Is the property listed above owned by someone other than you OR you and your spouse? No

Yes No

If yes, did that person reside with you in 2011? No Yes %

Yes

If the property was owned by someone other than you OR you and your spouse, did they pay any portion of the property tax? did they pay? What portion, if any, of the homestead property was rented or used for business in 2011?

If yes, what amount of the total property tax due

Members of Household - Name, Date of birth (MMDDYYYY), Relationship, Months in home, Income included on lines 4-9 (Y OR N), SSN. Enclose additional sheets if needed.

DORA MORA MARTHA ROSAS VALERIA GUTIERREZ DELIA ROQUE

10291960 05261992 07171999 08201931

MOTHER DAUGHTER NIECE PARENT

12 12 06 12

N N N N

931774471 931774467 926864374 981701467

Check this field if you wish to participate in the Refund Advancement Program.

I authorize the Director of Taxation or the Director's designee to discuss my K-40H and enclosure with my preparer. I declare under the penalties of perjury that to the best of my knowledge and belief this is a true, correct, and complete return. IMPORTANT: Please allow 20 to 24 weeks to process your refund. Renters should allow 28 weeks so the rent can be verified with your landlord.
Preparer Date Phone Number

Claimant's Signature Date

Preparer Signature

HOMESTEAD CLAIM 915 SW HARRISON ST TOPEKA KS 66699-2000

F o r

O f f i c e

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