Form 500 Form 500 Individual Income Tax Return and IND-CR Individual Credit Form (Fill in on-line, print and mail) (rev. 7/13)
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

000 05 Enclose with Form 500 2013 % Not to exceed 100% (: I) Unchecked (: LE) Unchecked (: S) Unchecked (: ZE) Unchecked (button) (button) (Check box if deceased) (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (COLUMN A) (COLUMN B) (COLUMN C) (combobox) SELECT (combobox) SELECT (combobox) SELECT (combobox) SELECT (combobox) SELECT (combobox) SELECT (COUNTRY IF FOREIGN) (Do not use FEDERAL TAXABLE INCOME) If the amount on Line 8 is $40 000 or more or your gross income is less than your W 2s (Enter Tax Withheld Only and enclose W 2s and/or 1099s) (Enter tota l but not more than the amount on Line 16) (For U S Accounts Only) (If you owe) Add Lines 23 26 thru 34 (IRC Section 199) (Must enclose G2 A G2 FL G2 LP and/or G2 RP) (PAYMENT) (Press to reset this form) RESET (PRINT) PRINT (PRINT) PRINT (REFUND and NO (Requires DNR certification for either credit) (See Tax Booklet on Page 12 Line 11) (See Tax Booklet Page 17 Line 10) (Sticky Note comment ERR (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) PLEASE USE THE GREEN PRINT BUTTON TO PRINT THIS FORM THANK YOU (Use 2nd address line for Apt Suite or Building Number) (Use Date Format: MM DD YYYY) (Use Date Format: MM DD YYYY) (Use Date Format: MM DD YYYY) (Use Date Format: MM DD YYYY) (Use Date Format: MM DD YYYY) (Use Date Format: MM DD YYYY) (Use Date Format: MM DD YYYY) 00 00 00 00 00 00 00 00 00 00 00 00 00 00 6a 1 2009 Acquisition indebtedness is debt incurred in acquiring constructing or substantially improving a qualified residence 1 5 0 00 1 Add Part 1 Line 3; Part 2 Line 3; Part 3 Line1; Part 4 Line 5; Part 5 Line 4; 1 Amount of child & dependent care expense credit 1 County of residence 1 Date assistance was received 1 Date of Successful Completion 1 Enter amount of qualified life insurance premiums and include in Part 10 1 FULL YEAR RESIDENT 1 Georgia Code Section 48 7 29 15 provides an income tax credit for the adoption of a qualified foster child The amount of 1 Interest on Non Georgia Municipal and State Bonds 1 1 Other State Credit(s) Tax Credit (See Tax Booklet on Page 15) 1 1 Purchase of a home that contains all four accessibility features OR total of accessibility 1 Qualified caregiving expenses 1 The physician must have started working in a rural county after July 1 1995 If the physician worked in a rural county prior 1 Total credit (Enter amount from 2009 IND CR Part 9 Line 5 ) 1 WAGES SALARIES TIPS etc 1 WAGES SALARIES TIPS etc 1/3 of the credit or the taxpayer s income tax liability Any unused tax credit can be carried forward but cannot be carried back 10 Any additional pass through credits claimed (Attach schedule) 10 10 Georgia adjusted gross income (Net total of Line 8 and Line 9) 10 Other Adjustments (Specify) 11 Low Income Credit (See Tax Booklet) 11a 11b 11 Standard Deduction (Do not use FEDERAL STANDARD DEDUCTION) 11 Total Subtractions (Enter sum of Lines 6 10 here) 11a Number on Line 6c 11c Add Lines 11a and 11b Enter total 12 Enter the total of Lines 1 through 11 here and on Line 17 Pg 2 of 500 form 12 12 Net Adjustments (Line 5 less Line 11) 12 Total Itemized Deductions used in computing Federal Taxable Income If you use itemized deductions you must enclose Federal Schedule A 12/11/2011 12:53:31 AM 13 Subtract either Line 11c or Line 12c from Line 10; enter balance 14a Number on Line 6c 14b Number on Line 7a multiplied by $3 000 14b 14c Add Lines 14a and 14b Enter total 14c 15 Georgia taxable income (Line 13 less Line 14c or Schedule 3 Line 14) 16 Tax (Use Tax Table in the Tax Booklet on Pages 20 22) 17 Credits from Schedule 2 Page 5 Line 12 of Form 500 18 Balance (Line 16 less Line 17) if zero or less than zero enter zero 1990 or any future such census For taxable years beginning on or after January 1 2012 the United States Decennial 1Page 2 33 33% 2 Amount of the disaster assistance received 2 Amount paid for the successfully completed course 2 County of practice 2 Credits from Form IND CR (Rural Physicians Credit Disabled Person Home Purchase or Retrofit Credit Driver Education Credit Disaster Assistance 2 Georgia allowable rate 2 INTERESTS AND DIVIDENDS 2 INTERESTSAND DIVIDENDS 2 Lump Sum Distributions 2 2 Maximum allowed per year 2 Maximum credit per residence 2 PART YEAR RESIDENT TO 3 NONRESIDENT 2 Percentage limitation 2 The physician must practice and reside in a rural county 20 Other Georgia Income Tax Withheld 2013 (Approved web version) Ending 21 Estimated ta x for 2013 and Form IT 560 22 Total prepayment credits (Add Lines 19 20 and 21) 23 If Line 18 exceeds Line 22 enter BALANCE DUE STATE 24 If Line 22 exceeds Line 18 enter OVERPAYMENT amount 25 Amount to be credited to 2014 ESTIMATED TAX 26 Georgia Wildlife Conservation Fund (No gift of less than $1 00) 27 Georgia Children and Elderly Fund (No gift of less than $1 00) 28 Georgia Cancer Research Fund (No gift of less than $1 00) 29 Statewide Land Conservation Program (No gift of less than $1 00) 2Page 3 Allowable Child & Dependent Care Expense Credit (Line 1 x 30) 3 BUSINESS INCOME OR (LOSS) 3 BUSINESS INCOME OR (LOSS) 3 Enter the lesser of Line 1 or Line 2 and include in Part 10 3 3 Federal deduction for income attributable to domestic production activities 3 3 Line 1 multiplied by Line 2 3 Maximum credit 3 Maximum credit 3 3 Maximum credit allowed (multiply Line 1 by Line 2) 3 The physician must be licensed to practice medicine in Georgia primarily admit patients to a rural hospital and practice in 3 Type of practice 30 Georgia National Guard Foundation (No gift of less than $1 00) 31 Dog & Cat Sterilization Fund (No gift of less than $1 00) 32 32 33 Georgia Student Finance Authority Fund (No gift of less than $1 00) 36 (If you are due a refund) Subtract the sum of Lines 25 thru 34 from Line 24 36a Direct Deposit 3Page 4 Date started working as a rural physician 4 Enter the lesser of Line 2 or Line 3 and include in Part 10 4 4 Enter unused credit (Total credit less amounts used in previous years) 4 Enter your Residency Status with the appropriate number 4 Maximum credit 4 Other (Specify) 4 OTHER INCOME OR (LOSS) 4 OTHER INCOME OR (LOSS) 48 2 31 requires that taxes shall be paid in lawful money of the United States free of any expenses to the State of Georgia 4Page 4Page 5 0 0 00 5 Clean Energy Property Credit (Individual/Non pass through) 5 5 Credit allowed smaller of line 3 or line 4 enter here and include in Part 10 5 Enter Filing Status with appropriate letter (See Tax Booklet Page 11 ) 5 5 Enter the lesser of Line 3 or Line 4 and include in Part 10 5 Number of hospital beds in the rural hospital 5 Total Additions (Enter sum of Lines 1 4 here) 5 5 TOTAL INCOME: TOTAL LINES 1 THRU 4 5 TOTAL INCOME: TOTAL LINES 1 THRU 4 500 UET Exception 6 COMPANY NAME 6 Number of exemptions (Check appropriate box(es) and enter total in 6c ) 6 Retirement Income Exclusion (See Tax Booklet on Page 11) 6 Rural physicians credit enter $5 000 and include in Part 10 6 TOTAL ADJUSTMENTS FROM FORM 1040 6 TOTAL ADJUSTMENTS FROM FORM 1040 6 TOTAL ADJUSTMENTS FROM FORM 1040 6a Yourself 6b Spouse 6c 7 COMPANY NAME 7 Dependents (If you have more than 3 dependents attach a list of additional dependents) 7 Social Security Benefits (Taxable portion from Federal return) 7 TOTAL ADJUSTMENTS FROM FORM 500 7 TOTAL ADJUSTMENTS FROM FORM 500 7a Number of Dependents (DO NOT include yourself or your spouse) 7b Add Lines 6c and 7a Enter total 8 ADJUSTED GROSS INCOME: 8 ADJUSTED GROSS INCOME: 8 COMPANY NAME 8 Federal adjusted gross income(From Federal Form 1040 1040A or 1040 EZ) 8 Georgia Higher Education Savings Plan 9 Adjustments from Schedule 1 (See Tax Booklet on Page 11 Line 9) 9 COMPANY NAME 9 Interest on United States Obligations (See Tax Booklet on Page 11) 9 9 RATIO: Divide Line 8 Column C by Line 8 Column A Enter percentage a credit equal to the lesser of the cost or $125 to retrofit an existing single family home with one or more of these features The a Federal Itemized Deductions (Schedule A Form 1040) a period of more than 90 consecutive days The credit shall be claimed and allowed in the year in which the majority of such A taxpayer is allowed the tax credit for a purchase of one eligible single family residence made between June 1 2009 and a) Any residence (including a new residence one occupied at the time of sale or a previously occupied residence) that was Account actual amount paid whichever is less A private driver training school is one that primarily engages in offering driving instruction ADDITIONS to INCOME ADDRESS ADDRESS (NUMBER AND STREET or P O BOX) (Use 2nd address line for Apt Suite or Building Number) ADDRESS (NUMBER AND STREET or P O BOX) CHECK IF ADDRESS HAS CHANGED Adjustment Amount Adjustment Amount Adoption Credit Eligible Single Family Residence Credit) 2 AFFIX Age if 62 or over agent; or amounts were excluded from Georgia net taxable income Any unused tax credit cannot be carried forward to any succeeding amounts were excluded from Georgia net taxable income There is no carryover or carry back available The credit cannot and are on active duty full time in the United States Armed Forces or active duty training in the United States Armed Forces for and which is secured by such residence Refinanced debt is acquisition debt if at least a portion of such debt refinances the ATLANTA GA 30348 5597 ATLANTA GA 30348 5613 ATLANTA GA 30374 0380 ATLANTA GA 30374 0399 Attached b Less adjustments: (See Tax Booket on Page 13 Line 12) b Self: 65 or over? Blind? Spouse: 65 or over? Blind? b) A residence with respect to which a foreclosure event has taken place and which is owned by the mortgagor or the mortgagor s BALANCE DUE) Beginning Birth Date Blue Label: PROCESSING CENTER by the Department of Revenue or have been issued a special permanent parking permit by the Department of Revenue c Georgia Total Itemized Deductions C Married filing separate (Spouse s social security number must be entered above) B Married filing joint A Single c Total Standard Deduction (Line 11a + Line 11b) c) An owner occupied residence with respect to which the owner s acquisition indebtedness was in default on or before March care equipment and other supplies which have been determined by a physician to be medically necessary Services must be Census of 2010 is used (see regulation 560 7 8 20 for transition rules) A listing of rural counties for purposes of the CHECK IF ADDRESS HAS CHANGED CITY (Please insert a space if city has multiple names) CITY (Please insert a space if the city has multiple names) STATE ZIP CODE claimed and allowed in the year in which the ninetieth day occurs The credit shall apply with respect to each taxable year in claimed on Federal Form 1040 completed course of driver education to a private or public high school does not qualify for this credit A completed costs by choosing Direct Deposit or Debit Card course of driver education includes additional courses offered by private driver training schools such as defensive driver education CREDIT CLAIMED ON THIS RETURN CREDIT CLAIMED ON THIS RETURN CREDIT CODE TYPE CREDIT CODE TYPE Credit Qualified Caregiving Expense Credit Georgia National Guard/Air National Guard Credit Child and Dependent Care Expense Credit D Head of Household or Qualifying Widow(er) Date of Disability: Type of Disability: b Spouse: Date of Birth days are served In the event an equal number of consecutive days are served in two calendar years then the exclusion shall be Debit Card defined as an acute care hospital located in a rural county that contains 80 or fewer beds For taxable years beginning on DEPARTMENT USE ONLY DEPENDENTS DEPOSIT OPTIONS disabled person must be the taxpayer or the taxpayer s spouse if a joint return is filed Qualified features are: Disaster assistance agency DO NOT USE LINES 9 THRU 14 OF PAGE 2 FORM 500 Do you want to authorize DOR to discuss this return with the electronically notify me at the below e mail address eligible single family residence is a single family structure (including a condominium unit as defined in O C G A 44 3 71) that emaNtsaLSocial Security Number Relationship to You ENCLOSE ALL ITEMS IN RETURN ENVELOPE DO NOT STAPLE YOUR CHECK W 2s OTHER WITHHOLDING DOCUMENTS OR TAX RETURN Enter $2 000 per qualified foster child and include in Part 10 Enter here and include in Part 10 3 Enter here and on Line 15 Page 2 of Form 500 Enter Net Total here and on Line 9 of Page 2 (+ or ) of Form 500 12 Enter the schedule total on Line 10 See Tax Booklet on Page 16 for a list of available credits and their applicable codes Enter the total here and on Form 500 Page 5 Schedule 2 Line 2 exceed the taxpayer s income tax liability For more information see Regulation 560 7 8 43 EXEMPTIONS expenses for a qualifying family member The credit cannot exceed $150 Qualified services include Home health agency features added to retrofit a home (up to $125 per feature) FEDERAL INCOME AFTER GEORGIA ADJUSTMENT Filing Status final and ending in the year in which the adopted child attains the age of 18 This credit applies to adoptions occuring in First Name MI First Name MI Last Name Fiscal Year For more information see Regulation 560 7 8 44 for sale prior to May 11 2009 and that remained for sale after May 11 2009; or For taxable years beginning on or after January 1 2003 a Form 500 UET (Estimated tax penalty) 34 Georgia Department of Revenue Georgia Department of Revenue Georgia Department of Revenue Georgia Department of Revenue Georgia Department of Revenue GEORGIA DEPARTMENT OF REVENUE GEORGIA DEPARTMENT OF REVENUE Georgia Department of Revenue (Approved web version) Georgia Emergency Management Agency or the Federal Emergency Management Agency The amount of the credit is equal Georgia Form 500 Georgia Form 500 Georgia Form 500(Rev 7 /13) Fiscal Year Georgia Form IND CR Georgia Form IND CR Georgia Form IND CR (Rev 7/13) Georgia Form500 Georgia Form500 Individual Income Tax Return Georgia Income Tax Withheld on Wages and 1099s Georgia Taxable Income: Subtract Line 13 from Line 8 Column C Grants from GEMA and/or FEMA Grants from the Department of Human Services Individual and Family Grant Program Green Label: HERESTEP https://etax dor ga gov/inctax/proposed regs/ruralphysiciancounties aspx I authorize the Georgia Department of Revenue to If amount on line 8 9 10 13 or 15 is negative us e t he min us sign ( ) Example 3 456 If disabled date of disability If you do not select Direct Deposit or Debit Card a Income earned in another state as a Geor gia resident is taxa ble but other state(s) INCOME NOT TAXABLE TO GEORGIA GEORGIA INCOME income tax return The credit is computed as follows: Individual Income Tax Return Individual Income Tax Return Individual Income Tax Return 5Page insurance coverage through the service member s Group Life Insurance Program administered by the United States Department insurance premiums nor the taxpayer s income tax liability Qualified life insurance premiums are the premiums paid for Interior passage doors providing at least a 32 inch wide opening is occupied for residential purposes by a single family that is: Itemized LABEL Last Name LAST NAME SUF FIX LAST NAME SUFF IX LAST NAME SUFFIX liability Any unused tax credit can be carried forward to the succeeding years tax liability but cannot be carried back to the liability for the purchase of a new single family home that contains all of the accessibility features listed below It also provides Light switches and outlets placed in accessible locations LINE 5 PLUS OR MINUS LINES 6 AND 7 LINE 5 PLUS OR MINUS LINES 6 AND 7 List the state(s) in which the income in Column B was earned and/or to which it was reported Loans from the Small Business Administration that are due to disasters declared by the President or Governor Low Emission Vehicle Credit or Zero Emission Vehicle Credit m u l t i p ly by $2 700 for filing status A or D MAKE CHECK PAYABLE TO GEORGIA DEPARTMENT OF REVENUE multiplied by $3 000 multiply by $2 700 for filing status A or D OR multiply by $3 700 for filing status B or C11b Number on Line 7a Multiply Line 12 by Ratio on Line 9 and enter result Name of dependent minor child NAME OF PREPARER OTHER THAN TAXPAYER Name of private driver training school Name: named preparer Yes No Balance To November 30 2009 The credit amount is the lesser of 1 2 percent of the purchase price of the eligible single family residence Number O C G A 48 7 29 1 provides a disabled person credit equal to the lesser of $500 per residence or the taxpayer s income tax O C G A 48 7 29 10 provides taxpayers with a credit for qualified child & dependent care expenses The credit is a percentage O C G A 48 7 29 17 provides taxpayers a credit for the purchase of an eligible single family residence located in Georgia An O C G A 48 7 29 2 provides a qualified caregiving expense credit equal to 10 percent of the cost of qualified caregiving O C G A 48 7 29 4 provides for a credit for a taxpayer who receives disaster assistance during a taxable year from the O C G A 48 7 29 5 provides for a driver education credit This is a credit for an amount paid for a dependent minor child for a O C G A 48 7 29 9 provides a tax credit for Georgia residents who are members of the National Guard or Air National Guard O C G A 48 7 29 provides for a $5 000 tax credit for rural physicians The tax credit may be claimed for not more than five obtained from an organization or individual not related to the taxpayer or the qualifying family member of the credit claimed and allowed under Internal Revenue Code 21 and claimed by the taxpayer on the taxpayer s Federal of Veterans Affairs Any unused tax credit is allowed to be carried forward to the taxpayer s succeeding year s tax liability One no step entrance allowing access into the residence or $1 800 00 The amount of the tax credit that may be claimed and allowed in a single tax year cannot exceed the lesser of or after January 1 2003 a rural hospital is defined as an acute care hospital located in a rural county that contains 100 or fewer beds For more information see Regulation 560 7 8 20 OR multiply by $3 700 for filing status B or C or Standard Deduction OWNERSHIP OWNERSHIP Page 2 Page 3 Page 4 Page 5 Page 5 Page 6 paper check will be issued Part 1 Disabled Person Home Purchase or Retrofit Credit Part 10 Total Section Part 2 Child and Dependent Care Expense Credit Part 3 Georgia National Guard/Air National Guard Credit Part 4 Qualified Caregiving Expense Credit Part 5 Driver Education Credit Part 6 Disaster Assistance Credit Part 6 Line 4; Part 7 Line 6; Part 8 Line 1; and Part 9 Line 5 Part 7 Rural Physicians Credit Part 8 Adoption of a Foster Child Credit Part 9 Eligible Single Family Residence Tax Credit Part Year Residents and Nonresidents must omit Lines 9 thru 14 and use Schedule 3 of Form 500 page 6 Pass Through Credits from Ownership of Sole Proprietor S Corp LLC or Partnership Interest and Other Credits Payments To Personal Exemption from Form 500 Page 2 (See Tax Booklet Pg 17 Line 11a c) PHONE NUMBER physician qualifies for the credit if they practice in a rural county and reside in a county contiguous to a rural county A PO BOX 105597 PO BOX 105613 PO BOX 740380 PO BOX 740399 PREPARER S FEIN PREPARER S SSN/PTIN principal amount of existing acquisition indebtedness PRINT prior years tax liability The approval letter from the disaster assistance agency must be enclosed with the return PROCESSING CENTER PROCESSING CENTER Qualified caregiving expenses do not include expenses that were subtracted to arrive at Georgia net taxable income or for which Qualified Education Expense Credit (Individual/Non pass through) qualify the physician must meet the following conditions: qualifying family member includes the taxpayer or an individual who is related to the taxpayer by blood marriage or adoption Qualifying Family Member Name: Refunds and regarding any updates to my account(s) Reinforcements in bathroom walls allowing installation of grab bars around the toilet tub and shower where Relationship Residency Status RESIDENTS AND NONRESIDENTS SCHEDULE 3 COMPUTATION OF GEORGIA TAXABLE INCOME FOR ONLY PART YEAR Routing rural county is defined as one with 65 or fewer persons per square mile according to the United States Decennial Census of rural physicians credit may be obtained at the following web page: Save the Cure Fund (No gift of less than $1 00) SCHEDULE 1 ADJUSTMENTS to INCOME BASED on GEORGIA LAW (SeeTax Booklet on Pages 11 and 12) SCHEDULE 1 PAGE 4 SCHEDULE 1 PAGE 4 SCHEDULE 2 CREDITS for LINE 17 PAGE 2 (See Tax Booklet on Pages 13 and 16) See Tax Booklet on Page 9 Select only one option See booklet page 13 Send 2D 500 services personal care services personal care attendant services homemaker services adult day care respite care or health Services under Chapter 13 of Title 43 The Driver Training School License Act The amount of the credit is equal to $150 or the Signature of Preparer Social Security Number Relationship to You Special Program Code SPOUSE S FIRST NAME MI Spouse s Signature (Check box if deceased) SPOUSE S SOCIAL SECURITY NUMBER STATE State of Georgia Individual Credit Form State of Georgia Individual Credit Form State of Georgia Individual Credit Form STEP 2 CONT STEP 5 TAX COMPUTATION STEP 4 DEDUCTIONS STEP 3 INCOME STEP 6 SIGNATURE STEP 5 TAX COMPUTATION CONTINUED subtracted by the taxpayer to arrive at Georgia taxable net income or with respect to any driver education expenses for which SUBTRACTION from INCOME successfully completed course of driver education at a private driver training school licensed by the Department of Driver such facilities are provided tax credit may apply See Tax Booklet Page 13 Line 17 and Page 15 TAXPAYER INFORMATIONSTEP TAXPAYER S EMAIL Taxpayer s Signature the credit is $2 000 per qualified foster child per taxable year commencing with the year in which the adoption becomes the fields of family practice obstetrics and gynecology pediatrics internal medicine or general surgery A rural hospital is The following types of assistance qualify: The qualifying family member must be at least age 62 or been determined disabled by the Social Security Administration A the taxable years beginning on or after January 1 2008 The taxpayer must have claimed the credit in 2009 in order to claim the unused credit below the taxpayer s income tax liability The credit is not allowed with respect to any driver education expenses either deducted or This does not include schools owned or operated by local state or federal governments An amount paid for a THIS IS YOUR REFUND This tax credit is only allowed once for each dependent minor child of a taxpayer The amount of the tax credit cannot exceed to $500 or the actual amount of the disaster assistance whichever is less The credit cannot exceed the taxpayer s income tax To qualify for this credit the disabled person must be permanently disabled and have been issued a permanent parking permit to that date a period of at least three years must have elapsed before the physician returns to work in a rural county Total Total Deductions and Exemptions: Add Lines 10 and 11c Total x 1 300= true correct and complete Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge Georgia Public Code Section Type of Disability: Date of Disability: a Self: Date of Birth Type: Checking Savings Under penalty of perjury I declare that I have examined this return including accompanying schedules and statements and to the best of my knowledge and belief it is Unmarked set by ERR) Use EITHER Line 11c OR Line 12c (Do not write on both lines) which such member serves for such qualifying period of time The credit cannot exceed the amount expended for qualified life years tax liability and cannot be carried back to any prior years tax liability Visit www dds ga gov/Training/index aspx years There is no carryover or carry back available The credit cannot exceed the taxpayer s income tax liability In order to You can help eliminate $1Million of processing you must enclose a copy of your Federal Form 1040 Pages 1 and 2 You must list the appropriate Credit Type Code in the space provided If you claim more than four credits enclose a schedule YOUR FIRST NAME MI YOUR SOCIAL SECURITY NUMBER YOUR SOCIAL SECURITY NUMBER YOUR SOCIAL SECURITY NUMBER YOUR SOCIAL SECURITY NUMBER YOUR SOCIAL SECURITY NUMBER YOUR SOCIAL SECURITY NUMBER ZIP CODE