Safe Harbor residents for the first time Failure to enclose a completed Worksheet A with your 1040ME may delay processing of your return
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(10 If you answered no to question 7(f) please explain the circumstances (Attach a separate sheet if necessary)
(15) 10
(15) 10
(15) 10
(2) 10
(2) 10
(2) 10
(If yes list employer (Yourself)
(If yes when? (Yourself)
(If yes when? (Yourself)
(If yes when? (Yourself)
(If yes when? (Yourself)
(If yes when? (Yourself)
(Name of other jurisdiction)
(Name of other jurisdiction)
(Name(s) as shown on Form 1040ME)
(NOTE: Married persons fi ling separate
(Period (mm/yy) From)
(Period (mm/yy) From)
(See instructions at www maine gov/revenue/forms) Enclose with your Form 1040ME
(Spouse [1])
(Spouse [2])
(Spouse [3])
(Spouse [4])
(Spouse)
(Spouse)
(Spouse)
(Spouse)
(Spouse)
(text)
(text)
(text)
(undefined)
(you intend to make of it and how often (Attach a separate sheet if necessary [1])
(you intend to make of it and how often (Attach a separate sheet if necessary [2])
**If necessary use Worksheet C (Employee Apportionment Worksheet) for Part Year Residents/Nonresidents/ Safe
*Part year residents must make an entry in Column C if income was earned in another jurisdiction during the
10 If you answered no to question 7(f) please explain the circumstances (Attach a separate sheet if necessary):
10 Rental real estate royalties
11 Farm income/loss
12 Unemployment Compensation
13 Taxable amount of social
14 Other income (Including lump sum
15 Add lines 1 through 14
Alimony received
and annuities
and Safe Harbor residents)
another state) (Enter date of move) 7
Attachment
Attended or sent your children (if any) to a Maine school 8e
Business income/loss
c Occupation 1c
Capital gain/loss
Column A Column B Column C* Column D Column E
Date of birth 1b
Did you ever apply for a Homestead or Veterans property tax exemption? 5b
distributions but excluding state
During 2012: Unless otherwise indicated enter Yes or No on each line
During period of nonresidency have you:
Enclose with your Form 1040ME
Enter new state of residence 7a
Enter state of prior residence 6a
Federal Income (Part year residents only) (Part year residents Nonresidents
federal return A for this period earned outside of Maine A for this period from Maine sources
for Part year Residents/Nonresidents/ Safe Harbor Residents
Harbor Residents to calculate the amount for line 1 Column E For a copy of Worksheet C go to the Maine Revenue
Have you disposed of the property? 5c
I became a Maine resident on (Enter Date) 6
I moved from Maine and became a nonresident (I established a legal residence in
I own(ed) a home/real property in Maine 5
I was domiciled in (Enter state(s)) 2
I was in the military and stationed in (Enter state or country) 3
If married did your spouse and dependent children (if any) move to your new
If yes in what municipality was the property located? 5a
If yes list employer (Yourself: Spouse: )
If yes when? (Yourself: Spouse: )
If yes when? (Yourself: Spouse: )
If yes when? (Yourself: Spouse: )
If yes when? (Yourself: Spouse: )
If yes when? (Yourself: Spouse: )
If you answered yes to question 5 but have not disposed of the property what use do
Income Allocation Worksheet for Part Year Residents/Nonresidents/ Safe Harbor Residents
Income from Income from Column Income from Column B Income from Column Income from Column D
income tax refunds)
line 1 of Schedule NR or Schedule NRH
Listed Maine as your legal residence for any purpose 8g
Maine income tax returns must complete
Maine Resident Period Nonresident Period
My designated state of legal residence was (Enter state) 3a
NAME 1
Name of other jurisdiction Period (mm/yy) From To
Name of other jurisdiction Period (mm/yy) From To
Name(s) as shown on Form 1040ME
nonresidents and Safe Harbor residents who are filing a Maine return for the first time and 3) former Maine residents who are filing as nonresidents or
NOTE: See instructions at www maine/gov/revenue/forms on how to use Worksheet B line 15 entries to complete
NR or Schedule NRH
Obtained a driver s license in Maine 6d
Obtained a driver s license in my new state of residence 7d
Obtained or renewed any Maine trade or professional licenses or union memberships 8h
Ordinary dividends
other compensation**
Other gains/losses
Part year residents Nonresidents and Safe Harbor residents must complete this worksheet before completing Schedule
partnerships S corporations and
Performed any work or services in Maine 8a
period of Maine residency Enter below the name of each other jurisdiction and the dates the income was earned in
Purchased a home in Maine 6c
Purchased a home in my new state of residence 7c
Purchased a Maine resident hunting or fi shing license 8f
Registered an auto or other vehicle in Maine 6e
Registered an auto or other vehicle in Maine 8b
Registered an auto or other vehicle in my new state of residence 7e
Registered to vote in Maine 6b
Registered to vote in my new state of residence 7b
Renewed a Maine driver s license 8c
security benefi ts
separate worksheets for each spouse)
Sequence No 8
Sequence No 9
Services web site at: www maine gov/revenue/forms or call (207) 624 7894 (to order)
Social security number 1a
state of residence? 7f
Taxable amount of IRA distributions
Taxable amount of pensions
Taxable interest
The following individuals must complete Worksheet A: 1) All part year residents whether moving into or out of Maine during the tax year; 2)
The number of days I spent in Maine (for any purpose) was 4
those jurisdictions Use a separate sheet if additional space is needed
trusts etc
Voted in Maine in person or by absentee ballot 8d
Wages salaries tips
WORKSHEET A Residency Information Worksheet
WORKSHEET B
you intend to make of it and how often (Attach a separate sheet if necessary)?
You must attach a copy of the income tax return(s) filed with the other jurisdiction
Your Social Security Number
Yourself Spouse