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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 RESIDENCE OR 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 $1 Spouse if filing jointly . . . . . Total Fill in if veteran of U.S. armed forces who served in Operation Enduring Freedom, Iraqi Freedom or Noble Eagle 3 You 3 Spouse 3$ 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 INCOME