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CERTAIN PART-YEAR RESIDENTS MUST ENCLOSE SCHEDULE HC

FOR PRIVACY ACT NOTICE, SEE INSTRUCTIONS.

Form 1-NR/PY Mass. Nonresident/Part-Year Resident Tax Return
FIRST NAME M.I. LAST NAME 1. YOUR SOCIAL SECURITY NUMBER SPOUSE’S FIRST NAME M.I. LAST NAME 2. SPOUSE’S SOCIAL SECURITY NUMBER

2012

ADDRESS

CITY/TOWN/POST OFFICE/FOREIGN COUNTRY

STATE

ZIP + 4

ADDRESS OF LEGAL RESIDENCEOR DOMICILE (IF FILING AS NONRESIDENT)

CITY/TOWN/POST OFFICE/FOREIGN COUNTRY

STATE OR FOREIGN COUNTRY

Attach, with a single staple, state copy of Forms W-2, W-2G and 1099 (showing Massachusetts withholding).

State Election Campaign Fund (this contribution will not change your tax or reduce your refund). . . . . . . . . . . . . . . $1 You $1 Spouse if filing jointly . . . . . TotalFill in if veteran of U.S. armed forces who served in Operation Enduring Freedom, Iraqi Freedom or Noble Eagle 3 You 3 Spouse 3$ If taxpayer(s) is deceased, fill in appropriate oval(s); see instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Primary Spouse Under age 18; see instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . 3 You 3 Spouse Select only one: Nonresident Filing as both a nonresident and 3 Fill in if name/address has changed since 2011 Part-year resident part-year resident (see instructions) 3 Fill in if noncustodial parent Nonresident composite return (see inst.) 3 Fill in if filing Schedule TDS (see instructions) FILING STATUS 3 Single (select one only)Married filing joint return (both must sign return) Married filing separate return (enter spouse’s Social Security number in the appropriate space above) Head of household (see instructions) 3 You are a custodial parent who has released claim to exemption for child(ren)

1

2

PART-YEAR RESIDENTS ONLY Dates as Massachusetts resident: From 3 To 3 ÷ 365 = 3 2 Whole-dollar method only TOTAL INCOMEfrom U.S. 1040, line 22; 1040A, line 15; 1040EZ, line 4; 1040NR, line 23; or 1040NR-EZ, line 7. If married filing separately, see instructions. . . . . . . . . . . . . . . . . . . . . . . . 3 3

Total days as Massachusetts resident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3 4

0 0
1 If showing a loss, mark an X in box at leftEXEMPTIONS a. Personal exemptions. If single or married filing separately, enter $4,400. If head of household, enter $6,800. If married filing jointly, enter $8,800 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4a b. Number of dependents. (Do not include yourself or your spouse.) You You Spouse Spouse Enter number 3 Enter number3 Enter number 3

0 0 0 0 0 0 0 0 0 0 0 0

You must enclose Schedule DI.

× $1,000 = 4b × $ 700 = 4c × $2,200 = 4d

c. Age 65 or over before 2013: d. Blindness: e. 1. Medical/ Dental 3

0 0
From U.S. Schedule A, line 4

2. Adoption 3

0 0
See instructions

1 + 2 = 4e

f. TOTAL EXEMPTIONS. Add lines 4a through 4e. Enter here and on line 22a. . . . . . . . . . . . . . . . . . .. . . . 3 4f

INCOME Nonresidents report in lines 5 through 11 Massachusetts source income only. Use line 13 if appropriate. Part-year residents report in lines 5 through 11 income earned and/or received while a resident. Do not use lines 13 or 14. If filing both as a nonresident and part-year resident, be sure to complete and enclose Schedule R/NR, Resident/Nonresident Worksheet, beforeproceeding any further.

5 6

Wages, salaries, tips and other employee compensation (from all Forms W-2) . . . . . . . . . . . . . . . . . 3 5 Taxable pensions and annuities (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 6

0 0 0 0

SIGN HERE. Under penalties of perjury, I declare that to the best of my knowledge and belief this return and...
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