1040 U.S.

Individual Income Tax Return 2020 (99)

Form Department of the Treasury—Internal Revenue Service

OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.

Filing Status Single Married filing jointly Married filing separately (MFS) Head of household (HOH) Qualifying widow(er) (QW)
Check only If you checked the MFS box, enter the name of your spouse. If you checked the HOH or QW box, enter the child’s name if the qualifying
one box.
person is a child but not your dependent a
Your first name and middle initial Last name Your social security number
Adam Mason 301-82-4207
If joint return, spouse’s first name and middle initial Last name Spouse’s social security number

Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Presidential Election Campaign
700 Barclay St 4 Check here if you, or your
spouse if filing jointly, want $3
City, town, or post office. If you have a foreign address, also complete spaces below. State ZIP code
to go to this fund. Checking a
Belpre OH 457141678 box below will not change
Foreign country name Foreign province/state/county Foreign postal code your tax or refund.
You Spouse

At any time during 2020, did you receive, sell, send, exchange, or otherwise acquire any financial interest in any virtual currency? Yes No

Standard Someone can claim: You as a dependent Your spouse as a dependent

Deduction Spouse itemizes on a separate return or you were a dual-status alien

Age/Blindness You: Were born before January 2, 1956 Are blind Spouse: Was born before January 2, 1956 Is blind
Dependents (see instructions): (2) Social security (3) Relationship (4)  if qualifies for (see instructions):
(1) First name Last name number to you Child tax credit Credit for other dependents
If more
than four
dependents,
see instructions
and check
here a
1 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . . . . . 1
Attach 2a Tax-exempt interest . . . 2a 2b
b Taxable interest . . . . .
Sch. B if
3a Qualified dividends . . . 3a b Ordinary dividends . . . . . 3b
required.
4a IRA distributions . . . . 4a b Taxable amount . . . . . . 4b
5a Pensions and annuities . . 5a b Taxable amount . . . . . . 5b
Standard 6a Social security benefits . . 6a b Taxable amount . . . . . . 6b
Deduction for— a
7 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . 7
• Single or
Married filing 8 Other income from Schedule 1, line 9 . . . . . . . . . . . . . . . . . . . 8
separately, a
$12,400 9 Add lines 1, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . . . . . . . . 9
• Married filing 10 Adjustments to income:
jointly or
Qualifying a From Schedule 1, line 22 . . . . . . . . . . . . . . 10a
widow(er),
$24,800
b Charitable contributions if you take the standard deduction. See instructions 10b
• Head of c Add lines 10a and 10b. These are your total adjustments to income . . . . . . . . a 10c
household, a
$18,650 11 Subtract line 10c from line 9. This is your adjusted gross income . . . . . . . . . 11
• If you checked 12 Standard deduction or itemized deductions (from Schedule A) . . . . . . . . . . 12 12,400.
any box under
Standard 13 Qualified business income deduction. Attach Form 8995 or Form 8995-A . . . . . . . . 13
Deduction,
see instructions.
14 Add lines 12 and 13 . . . . . . . . . . . . . . . . . . . . . . . . 14 12,400.
15 Taxable income. Subtract line 14 from line 11. If zero or less, enter -0- . . . . . . . . . 15 0.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2020)
Form 1040 (2020) Page 2
16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 . . 16 0.
17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . . . . 17
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . 18 0.
19 Child tax credit or credit for other dependents . . . . . . . . . . . . . . . . 19
20 Amount from Schedule 3, line 7 . . . . . . . . . . . . . . . . . . . . 20
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . 21
22 Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . . . . . . . . . 22 0.
23 Other taxes, including self-employment tax, from Schedule 2, line 10 . . . . . . . . . 23 0.
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . . . . . . a 24 0.
25 Federal income tax withheld from:
a Form(s) W-2 . . . . . . . . . . . . . . . . . . 25a
b Form(s) 1099 . . . . . . . . . . . . . . . . . . 25b
c Other forms (see instructions) . . . . . . . . . . . . . 25c
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . . . . 25d
• If you have a 26 2020 estimated tax payments and amount applied from 2019 return . . . . . . . . . . 26
qualifying child, 27 Earned income credit (EIC) . . . . . . . . . . . . No. . 27
attach Sch. EIC.
• If you have 28 Additional child tax credit. Attach Schedule 8812 . . . . . . . 28
nontaxable 29 American opportunity credit from Form 8863, line 8 . . . . . . . 29
combat pay,
see instructions. 30 Recovery rebate credit. See instructions . . . . . . . . . . 30 1,800.
31 Amount from Schedule 3, line 13 . . . . . . . . . . . . 31
32 Add lines 27 through 31. These are your total other payments and refundable credits . . . a 32 1,800.
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . a 33 1,800.
Refund 34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . 34 1,800.
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . a 35a 1,800.
Direct deposit? ab Routing number 0 4 4 0 0 0 0 2 4 a c Type: Checking Savings
See instructions. a
d Account number 0 2 7 7 8 1 0 0 0 6 5
36 Amount of line 34 you want applied to your 2021 estimated tax . . a 36
Amount 37 Subtract line 33 from line 24. This is the amount you owe now . . . . . . . . . . a 37
You Owe Note: Schedule H and Schedule SE filers, line 37 may not represent all of the taxes you owe for
For details on 2020. See Schedule 3, line 12e, and its instructions for details.
how to pay, see
instructions. 38 Estimated tax penalty (see instructions) . . . . . . . . . a 38
Third Party Do you want to allow another person to discuss this return with the IRS? See
Designee instructions . . . . . . . . . . . . . . . . . . . . a Yes. Complete below. No
Designee’s Phone Personal identification
name a no. a number (PIN) a
Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and
Sign belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here Your signature Date Your occupation If the IRS sent you an Identity
Protection PIN, enter it here
F

Joint return? Janitor (see inst.) a

See instructions. Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent your spouse an
Keep a copy for Identity Protection PIN, enter it here
your records. (see inst.) a
Phone no. Email address
Preparer’s name Preparer’s signature Date PTIN Check if:
Paid Self-employed
Preparer Firm’s name a Self-Prepared Phone no.
Use Only Firm’s address a Firm’s EIN a

Go to www.irs.gov/Form1040 for instructions and the latest information. BAA REV 03/25/21 Intuit.cg.cfp.sp Form 1040 (2020)
 Do not staple or paper clip. 0033 2020 Ohio IT 1040
hio Department of
Taxation
Individual Income Tax Return
Use only black ink/UPPERCASE letters. 20000133
04 04 21 Sequence No. 1

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REV 03/26/21 INTUIT.CG.CFP.SP Rev. 9/9/20. IT 1040 – page 1 of 2

 0033 2020 Ohio IT 1040
Individual Income Tax Return
SSN 301 82 4207
20000233 Sequence No. 2

D$PRXQWIURPOLQHRQSDJH ........................................................................................................ 7a. 0 00

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17. Amended return only±DPRXQWSUHYLRXVO\SDLGZLWKRULJLQDODQGRUDPHQGHGUHWXUQ .............................17. 00
Total Ohio tax payments (add lines 14, 15, 16 and 17) ............................................................................ 00
Amended return only±RYHUSD\PHQWSUHYLRXVO\UHTXHVWHGRQRULJLQDODQGRUDPHQGHGUHWXUQ .............. 00
/LQHPLQXVOLQH3ODFHDLQWKHER[DWWKHULJKWLIWKHDPRXQWLVOHVVWKDQ]HUR........................... ....20. 00
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REV 03/26/21 INTUIT.CG.CFP.SP Rev. 9/9/20. IT 1040 – page 2 of 2

 0033
2020 Ohio Schedule of Credits
hio Department of
Taxation Primary taxpayer’s SSN

20280133 Sequence No. 7

04 04 21 301 82 4207
Nonrefundable Credits
1. Tax liability before credits (from Ohio IT 1040, line 8c) .............................................................................. 1. 0 00
2. Retirement income credit (see instructions for table; include 1099-R forms) ........................................... 2. 00
3. Lump sum retirement credit (see instructions for worksheet; include a copy) ....................................... 3. 00
4. Senior citizen credit (must be 65 or older to claim this credit) ................................................................. 4. 00
5. Lump sum distribution credit (see instructions for worksheet; include a copy) ...................................... 5. 00
6. Child care & dependent care credit (see instructions for worksheet; include a copy)......................... ... 6. 00
7. Displaced worker training credit (see instructions for all required documentation; include copies) ....... 7. 00

 D &DPSDLJQFRQWULEXWLRQFUHGLWIRU2KLRVWDWHZLGHRႈFHRU*HQHUDO$VVHPEO\ ........................................ 7a. 0 00

8. Income-based exemption credit ($20 times the number of exemptions) ................................................. 8. 20 00

9. Total (add lines 2 through 8) .................................................................................................................... 9. 20 00

10. Tax less credits (line 1 minus line 9; if less than zero, enter zero) ......................................................... 10. 0 00

  -RLQW¿OLQJFUHGLWVHHLQVWUXFWLRQVIRUWDEOHWLPHVOLQHXSWR.....11. 0 00

12. Earned income credit ............................................................................................................................. 12. 00

13. Ohio adoption credit ............................................................................................................................... 13. 00

14. Nonrefundable job retention credit (LQFOXGHDFRS\RIWKHFUHGLWFHUWL¿FDWH) ..................................... 14. 00

15. Credit for eligible new employees in an enterprise zone (LQFOXGHDFRS\RIWKHFUHGLWFHUWL¿FDWH) ... 15. 00

16. Credit for purchases of grape production property ................................................................................ 16. 00

17. InvestOhio credit (LQFOXGHDFRS\RIWKHFUHGLWFHUWL¿FDWH) ................................................................ 17. 00

18. Lead abatement credit (LQFOXGHDFRS\RIWKHFUHGLWFHUWL¿FDWH) ....................................................... 18. 00

19. Opportunity zone investment credit (LQFOXGHDFRS\RIWKHFUHGLWFHUWL¿FDWH) .................................... 19. 00

20. Technology investment credit carryforward (LQFOXGHDFRS\RIWKHFUHGLWFHUWL¿FDWH) ........................ 20. 00

21. Enterprise zone day care & training credits (LQFOXGHDFRS\RIWKHFUHGLWFHUWL¿FDWH) ....................... 21. 00

22. Research & development credit (LQFOXGHDFRS\RIWKHFUHGLWFHUWL¿FDWH) ......................................... 22. 00

23. Nonrefundable Ohio historic preservation credit (LQFOXGHDFRS\RIWKHFUHGLWFHUWL¿FDWH) ................ 23. 00

24. Total (add lines 11 through 23) ............................................................................................................... 24. 0 00

25. Tax less additional credits (line 10 minus line 24; if less than zero, enter zero) .................................... 25. 0 00

REV 03/26/21 INTUIT.CG.CFP.SP

Schedule of Credits – page 1 of 2

 0033
2020 Ohio Schedule of Credits
Primary taxpayer’s SSN
20280233
301 82 4207 Sequence No. 8
Nonresident Credit

Date of nonresidency to State of residency

26. Nonresident Portion of Ohio adjusted gross income -

Ohio IT NRC Section I, line 18 (include a copy) ............ 26. 00

27. Ohio adjusted gross income (Ohio IT 1040, line 3) ........ 27. 00

28. Divide line 26 by line 27 and enter the result here (four digits; do not round).
Multiply this factor by line 25 to calculate your nonresident credit ......................................................... 28. 00
Resident Credit

29. Portion of Ohio adjusted gross income taxed by another

state or the District of Columbia while an Ohio resident-
Ohio IT RC, line 1a (include a copy) .............................. 29. 00

30. Ohio adjusted gross income (Ohio IT 1040, line 3) ........30. 00

31. Divide line 29 by line 30 and enter the result here (four digits; do not round).
Multiply this factor by line 25 and enter the result
here ................................................................................31. 00
32. 2020 income tax liability after credits paid to
another state or the District of Columbia
Ohio IT RC, line 1b (include a copy) ..............................32. 00

33. Enter the lesser of line 31 or line 32. This is your Ohio resident tax credit. Enter the two-letter
state abbreviation in the boxes below for each state in which income was subject to tax ..................... 33. 00

34. Total nonrefundable credits (add lines 9, 24, 28 and 33; enter here and on Ohio IT 1040, line 9) .... 34. 20 00

Refundable Credits

35. Refundable Ohio historic preservation credit (LQFOXGHDFRS\RIWKHFUHGLWFHUWL¿FDWH) ..................... 35. 00

36. Refundable job creation credit & job retention credit (LQFOXGHDFRS\RIWKHFUHGLWFHUWL¿FDWH) ..................36. 00

37. Pass-through entity credit (include a copy of the Ohio IT K-1s) ......................................................... 37. 00

38. Motion picture & Broadway theatrical production credit (LQFOXGHDFRS\RIWKHFUHGLWFHUWL¿FDWH) ..... 38. 00

39. Venture capital credit (LQFOXGHDFRS\RIWKHFUHGLWFHUWL¿FDWH) ......................................................... 39. 00

40. Total refundable credits (add lines 35 through 39; enter here and on Ohio IT 1040, line 16) ............. 40. 00

REV 03/26/21 INTUIT.CG.CFP.SP

Schedule of Credits – page 2 of 2

 1040 U.S. Individual Income Tax Return 2020 (99)
Form Department of the Treasury—Internal Revenue Service

OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.

Filing Status Single Married filing jointly Married filing separately (MFS) Head of household (HOH) Qualifying widow(er) (QW)
Check only If you checked the MFS box, enter the name of your spouse. If you checked the HOH or QW box, enter the child’s name if the qualifying
one box.
person is a child but not your dependent a
Your first name and middle initial Last name Your social security number
Adam Mason 301-82-4207
If joint return, spouse’s first name and middle initial Last name Spouse’s social security number

Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Presidential Election Campaign
700 Barclay St 4 Check here if you, or your
spouse if filing jointly, want $3
City, town, or post office. If you have a foreign address, also complete spaces below. State ZIP code
to go to this fund. Checking a
Belpre OH 457141678 box below will not change
Foreign country name Foreign province/state/county Foreign postal code your tax or refund.
You Spouse

At any time during 2020, did you receive, sell, send, exchange, or otherwise acquire any financial interest in any virtual currency? Yes No

Standard Someone can claim: You as a dependent Your spouse as a dependent

Deduction Spouse itemizes on a separate return or you were a dual-status alien

Age/Blindness You: Were born before January 2, 1956 Are blind Spouse: Was born before January 2, 1956 Is blind
Dependents (see instructions): (2) Social security (3) Relationship (4)  if qualifies for (see instructions):
(1) First name Last name number to you Child tax credit Credit for other dependents
If more
than four
dependents,
see instructions
and check
here a
1 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . . . . . 1
Attach 2a Tax-exempt interest . . . 2a 2b
b Taxable interest . . . . .
Sch. B if
3a Qualified dividends . . . 3a b Ordinary dividends . . . . . 3b
required.
4a IRA distributions . . . . 4a b Taxable amount . . . . . . 4b
5a Pensions and annuities . . 5a b Taxable amount . . . . . . 5b
Standard 6a Social security benefits . . 6a b Taxable amount . . . . . . 6b
Deduction for— a
7 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . 7
• Single or
Married filing 8 Other income from Schedule 1, line 9 . . . . . . . . . . . . . . . . . . . 8
separately, a
$12,400 9 Add lines 1, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . . . . . . . . 9
• Married filing 10 Adjustments to income:
jointly or
Qualifying a From Schedule 1, line 22 . . . . . . . . . . . . . . 10a
widow(er),
$24,800
b Charitable contributions if you take the standard deduction. See instructions 10b
• Head of c Add lines 10a and 10b. These are your total adjustments to income . . . . . . . . a 10c
household, a
$18,650 11 Subtract line 10c from line 9. This is your adjusted gross income . . . . . . . . . 11
• If you checked 12 Standard deduction or itemized deductions (from Schedule A) . . . . . . . . . . 12 12,400.
any box under
Standard 13 Qualified business income deduction. Attach Form 8995 or Form 8995-A . . . . . . . . 13
Deduction,
see instructions.
14 Add lines 12 and 13 . . . . . . . . . . . . . . . . . . . . . . . . 14 12,400.
15 Taxable income. Subtract line 14 from line 11. If zero or less, enter -0- . . . . . . . . . 15 0.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2020)
Form 1040 (2020) Page 2
16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 . . 16 0.
17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . . . . 17
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . 18 0.
19 Child tax credit or credit for other dependents . . . . . . . . . . . . . . . . 19
20 Amount from Schedule 3, line 7 . . . . . . . . . . . . . . . . . . . . 20
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . 21
22 Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . . . . . . . . . 22 0.
23 Other taxes, including self-employment tax, from Schedule 2, line 10 . . . . . . . . . 23 0.
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . . . . . . a 24 0.
25 Federal income tax withheld from:
a Form(s) W-2 . . . . . . . . . . . . . . . . . . 25a
b Form(s) 1099 . . . . . . . . . . . . . . . . . . 25b
c Other forms (see instructions) . . . . . . . . . . . . . 25c
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . . . . 25d
• If you have a 26 2020 estimated tax payments and amount applied from 2019 return . . . . . . . . . . 26
qualifying child, 27 Earned income credit (EIC) . . . . . . . . . . . . No. . 27
attach Sch. EIC.
• If you have 28 Additional child tax credit. Attach Schedule 8812 . . . . . . . 28
nontaxable 29 American opportunity credit from Form 8863, line 8 . . . . . . . 29
combat pay,
see instructions. 30 Recovery rebate credit. See instructions . . . . . . . . . . 30 1,800.
31 Amount from Schedule 3, line 13 . . . . . . . . . . . . 31
32 Add lines 27 through 31. These are your total other payments and refundable credits . . . a 32 1,800.
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . a 33 1,800.
Refund 34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . 34 1,800.
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . a 35a 1,800.
Direct deposit? ab Routing number 0 4 4 0 0 0 0 2 4 a c Type: Checking Savings
See instructions. a
d Account number 0 2 7 7 8 1 0 0 0 6 5
36 Amount of line 34 you want applied to your 2021 estimated tax . . a 36
Amount 37 Subtract line 33 from line 24. This is the amount you owe now . . . . . . . . . . a 37
You Owe Note: Schedule H and Schedule SE filers, line 37 may not represent all of the taxes you owe for
For details on 2020. See Schedule 3, line 12e, and its instructions for details.
how to pay, see
instructions. 38 Estimated tax penalty (see instructions) . . . . . . . . . a 38
Third Party Do you want to allow another person to discuss this return with the IRS? See
Designee instructions . . . . . . . . . . . . . . . . . . . . a Yes. Complete below. No
Designee’s Phone Personal identification
name a no. a number (PIN) a
Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and
Sign belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here Your signature Date Your occupation If the IRS sent you an Identity
Protection PIN, enter it here
F

Joint return? Janitor (see inst.) a

See instructions. Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent your spouse an
Keep a copy for Identity Protection PIN, enter it here
your records. (see inst.) a
Phone no. Email address
Preparer’s name Preparer’s signature Date PTIN Check if:
Paid Self-employed
Preparer Firm’s name a Self-Prepared Phone no.
Use Only Firm’s address a Firm’s EIN a

Go to www.irs.gov/Form1040 for instructions and the latest information. BAA REV 03/25/21 Intuit.cg.cfp.sp Form 1040 (2020)
 IT-140
REV 7-20 West Virginia Personal Income Tax Return 2020
SOCIAL Deceased *SPOUSE’S Deceased
SECURITY SOCIAL SECURITY
NUMBER 301824207 Date of Death: NUMBER Date of Death:
YOUR
LAST NAME SUFFIX FIRST MI
MASON NAME ADAM
SPOUSE’S
SPOUSE’S
SUFFIX FIRST MI
LAST NAME
NAME

FIRST LINE OF SECOND LINE

ADDRESS OF ADDRESS
700 BARCLAY ST APT 4
CITY STATE ZIP CODE
BELPRE OH 457141678
TELEPHONE EXTENDED DUE DATE
EMAIL
NUMBER MM/DD/YYYY
3046156195 ADAM.MASON2013@GMA
Amended Check before 4/15/21 if you wish to stop the original debit Nonresident Nonresident/ Form WV-8379 ¿led as
return (amended return only) Special
X Part-Year Resident an injured spouse

{
Yourself (a) 1
FILING Exemptions (If someone can claim you as a dependent, leave box (a) blank.)
Enter “1” in boxes a
and b if they apply Spouse (b)
STATUS c. List your dependents. If more than ¿ve dependents, continue on Schedule DP on page 40.
Social Security Date of Birth
(Check One)
First name Last name Number (MM DD YYYY)
1 X Single

2 Head of Household

3 Married, Filing Joint

4 Married, Filing
Separate
*Enter spouse’s SS# and
name in the boxes above

d. Additional exemption if surviving spouse (see page 17) Enter total number of dependents (c)
5 Widow(er) with Enter decedents SSN: ______________________ Year Spouse Died: _____________________ (d)
dependent child e. Total Exemptions (add boxes a, b, c, and d). Enter here and on line 6 below. If box e is zero, enter $500 on line 6 below. (e) 1

1. Federal Adjusted Gross Income or income to claim senior citizen tax credit from Schedule SCTC-1 1 .00

2. Additions to income (line 56 of Schedule M)............................................................................................. 2 .00

3. Subtractions from income (line 48 of Schedule M).................................................................................... 3 .00

4. West Virginia Adjusted Gross Income (line 1 plus line 2 minus line 3)...................................................... 4 .00

5. Low-Income Earned Income Exclusion (see worksheet on page 23)........................................................ 5 .00

1 x $2,000 ........................................
6. Total Exemptions as shown above on Exemption Box (e) ________ 6 2000 .00

7. West Virginia Taxable Income (line 4 minus lines 5 & 6) IF LESS THAN ZERO, ENTER ZERO ............ 7 0 .00

8. Income Tax Due (Check One) ................................................................................................................. 8 0 .00

Tax Table Rate Schedule X Nonresident/Part-year resident calculation schedule

TAX DEPT USE ONLY

MUST INCLUDE WITHHOLDING
PAY
PLAN
COR SCTC NRSR HEPTC FORMS WITH THIS RETURN
(W-2s, 1099s, Etc.)

1555 REV 03/17/21 INTUIT.CG.CFP.SP

*T O 4 0 2 0 2 0 0 1*
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 PRIMARY LAST NAME
SHOWN ON FORM SOCIAL SECURITY 8.Total Taxes Due
IT-140 MASON NUMBER 301824207 (line 8 from previous page) 8 0 .00

9. Credits from Tax Credit Recap Schedule (see schedule on page 5 ) (now includes the Family Tax Credit) 9 .00

10. Line 8 minus 9. If line 9 is greater than line 8, enter 0 10 0 .00

11. Overpayment previously refunded or credited (amended return only) ........................................................... 11 .00

12. Penalty Due from Form IT-210 CHECK IF REQUESTING WAIVER/ANNUALIZED WORKSHEET ATTACHED If you owe penalty, enter here 12 .00
13. West Virginia Use Tax Due on out-of-state purchases
(See Schedule UT on page 9). X CHECK IF NO USE TAX DUE ............... 13 .00

14. Add lines 10 through 13. This is your total amount due................................................................................. 14 0 .00

Check if withholding from NRSR .00

15. West Virginia Income Tax Withheld (See instructions) (Nonresident Sale of Real Estate) 15

16. Estimated Tax Payments and Payments with Schedule 4868 ....................................................................... 16 0 .00

17. Non-Family Adoption Tax Credit if applicable (include Schedule WV NFA-1) ................................................ 17 .00

18. Senior Citizen Tax Credit for property tax paid (include Schedule SCTC-1) .................................................. 18 .00

19. Homestead Excess Property Tax Credit for property tax paid (include Schedule HEPTC-1) ....................... 19 .00

20. Amount paid with original return (amended return only) ................................................................................ 20 .00

21. Payments and Refundable Credits (add lines 15 through 20) ....................................................................... 21 0 .00

22. Balance Due (line 14 minus line 21). If Line 21 is greater than line 14, complete line 23 ..... PAY THIS AMOUNT 22 .00

23. Line 21 minus line 14. This is your overpayment ......................................................................................... 23 0 .00
24. Donations of part or all of line 23. Indicate below and enter the sum of columns 24A, 24B, and 24C on Line 24
24A. WEST VIRGINIA 24B. WEST VIRGINIA DEPARTMENT OF 24C. DONEL C. KINNARD MEMORIAL
CHILDREN’S TRUST FUND VETERANS ASSISTANCE STATE VETERANS CEMETERY

24 .00

25. Amount of Overpayment to be credited to your 2021 estimated tax............................................................... 25 .00

26. Refund due to you (line 23 minus line 24 and line 25).............................................................. REFUND 26 0 .00
Direct Deposit
of Refund CHECKING SAVINGS
ROUTING NUMBER ACCOUNT NUMBER
PLEASE REVIEW YOUR ACCOUNT INFORMATION FOR ACCURACY. INCORRECT ACCOUNT INFORMATION MAY RESULT IN A $15.00 RETURNED PAYMENT CHARGE.

I authorize the State Tax Department to discuss my return with my preparer YES NO

Under penalty of perjury, I declare that I have examined this return, accompanying schedules, and statements, and to the best of my knowledge and belief, it is true, correct and complete.

Your Signature Date Spouse’s Signature Date Telephone Number

Preparer: Check
HERE if client is
requesting that form
NOT be e-¿led Preparer’s EIN Signature of preparer other than above Date Telephone Number

SELF-PREPARED
Preparer’s Printed Name Preparer’s Firm

FOR REFUND, MAIL TO THIS ADDRESS: FOR BALANCE DUE, MAIL TO THIS ADDRESS:
WV STATE TAX DEPARTMENT WV STATE TAX DEPARTMENT
P.O. BOX 1071 P.O. BOX 3694
CHARLESTON, WV 25324-1071 CHARLESTON, WV 25336-3694
Payment Options: Returns ¿led with a balance of tax due may pay through any of the following methods:
• Check or Money Order payable to the WV State Tax Department - Enclose check or money order with your return.
• Electronic Payment - May be made by visiting mytaxes.wvtax.gov and clicking on “Pay Personal Income Tax”. *T O 4 0 2 0 2 0 0 2*
• Credit Card Payment – May be made by visiting the Treasurer’s website at: epay.wvsto.com/tax
REV 03/17/21 INTUIT.CG.CFP.SP
1555 –2–
 2020
SCHEDULE
A Nonresidents/Part-Year Residents
(F඗කඕ IT-140) Schedule of Income
PART-YEAR RESIDENTS: FROM: TO:
Enter period of West Virginia residency MM/DD/YYYY MM/DD/YYYY

(To Be Completed By Nonresidents and Part-Year Residents Only) COLUMN A: COLUMN B: COLUMN C:
ALL INCOME DURING PERIOD OF WV SOURCE INCOME DURING
INCOME AMOUNT FROM FEDERAL RETURN WV RESIDENCY NONRESIDENT PERIOD

1. Wages, salaries, tips (withholding documents).......... 1 .00 .00 .00

2. Interest .................................................................... 2 .00 .00 .00

3. Dividends ................................................................ 3 .00 .00 .00

4. IRAs, pensions and annuities .................................. 4 .00 .00 .00

5. Total taxable Social Security and Railroad Retirement
bene¿ts (see line 33 and 38 of Schedule M) ............. 5 .00 .00
6. Refunds of state and local income tax
(see line 36 of Schedule M) .................................... 6 .00 .00

7. Alimony received .................................................... 7 .00 .00

8. Business pro¿t (or loss) .......................................... 8 .00 .00 .00

9. Capital gains (or losses) ......................................... 9 .00 .00 .00

10. Supplemental gains (or losses) .............................. 10 .00 .00 .00

11. Farm income (or loss) ............................................. 11 .00 .00 .00

12. Unemployment compensation insurance ............. 12 .00 .00 .00

13. Other income from federal return (identify source)
13 .00 .00 .00

14. Total income (add lines 1 through 13) ..................... 14 .00 .00 .00
ADJUSTMENTS

15. Educator expenses ................................................ 15 .00 .00 .00

16. IRA deduction ......................................................... 16 .00 .00 .00

17. Self-employment tax deduction ............................... 17 .00 .00 .00

18. Self Employed SEP, SIMPLE and quali¿ed plans... 18 .00 .00 .00

19. Self-employment health insurance deduction ..... 19 .00 .00 .00

20. Penalty for early withdrawal of savings .................. 20 .00 .00 .00

21. Other adjustments (See instructions page 25) ....... 21 .00 .00 .00

22. Total adjustments (add lines 15 through 21) ........... 22 .00 .00 .00
23. Adjusted gross income
(subtract line 22 from line 14 in each column) ........ 23 .00 .00 .00

24. West Virginia income (line 23, Column B plus column C) .............................................................................. 24 .00
25. Income subject to West Virginia state tax but
exempt from federal tax...................................... 25 .00
26. Total West Virginia income (line 24 plus line 25).
Enter here and on line 2 on the next page 26 .00
*T O 4 0 2 0 2 0 0 7* 1555 REV 03/17/21 INTUIT.CG.CFP.SP

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 2020
SCHEDULE
A Nonresidents/Part-Year Residents
(F඗කඕ IT-140) Schedule of Income
SCHEDULE A (CONTINUED)

PART I: NONRESIDENT/PART-YEAR RESIDENT TAX CALCULATION

1. Tentative Tax (apply the appropriate tax rate schedule on page 37 to the amount shown on line 7, Form IT-140)..... 1 0 .00

2. West Virginia Income (line 26, Schedule A)............................................................................................................. 2 .00

3. Federal Adjusted Gross Income (line 1, Form IT-140).............................................................................................. 3 .00

4. Tax (divide line 2 by line 3, round to 4 decimal places and multiply the result by line 1). Enter here and on line 8,
Form IT-140 .......................................................................................................................................................... 4 0 .00
PART II: SPECIAL NONRESIDENT INCOME FOR RESIDENTS OF RECIPROCAL STATES
AND CERTAIN ACTIVE MILITARY MEMBERS
ELIGIBILITY: Complete this section ONLY if ALL THREE of the following statements were true for 2020.
• You were EITHER a resident of Kentucky, Maryland, Ohio, Pennsylvania or Virginia
OR a member of the military assigned to active duty in West Virginia whose domicile is outside West Virginia
• Your only West Virginia source income was from wages and salaries.
• West Virginia income tax was withheld from such wages and salaries by your employer(s).

If you were a non-military, domiciliary resident of Pennsylvania or Virginia and spent more than 183 days in West Virginia, you are also considered a
resident of West Virginia and must ¿le Form IT-140 as a resident of West Virginia.
NOTE: If you were a resident of any state other than Kentucky, Ohio, Maryland, Pennsylvania, or Virginia, you are ineligible to complete Part
II. You must check the box Filing as Nonresident or Filing as a Part-Year Resident and Complete Schedule A and Part I to report any income
from West Virginia sources.
I declare that I was not a resident of West Virginia at any time during 2020, I was a resident of the state shown OR was in West Virginia
pursuant to active duty military orders, my only income from sources within West Virginia was from wages and salaries, and such wages
and salaries were subject to income taxation by my state of residence.

YOUR STATE OF RESIDENCE (Check one):

Commonwealth of Kentucky Commonwealth of Pennsylvania Number of days spent in West Virginia

State of Maryland Commonwealth of Virginia Number of days spent in West Virginia

State of Ohio Active Military, stationed in West Virginia but not domiciled here (Must enclose military order and DD2058)
(A) (B)
Primary Taxpayer's Social Spouse's Social Security
Security Number Number

5. Enter your total West Virginia Income from wages and salaries in the appropriate column 5 .00 .00
6. Enter total amount of West Virginia Income Tax withheld from your wages and
salaries paid by your employer in 2020.................................................................... 6 .00 .00

7. Line 6, column A plus line 6 column B. Report this amount on line 15 of Form IT-140...................................... 7 .00

1555 REV 03/17/21 INTUIT.CG.CFP.SP *T O 4 0 2 0 2 0 0 8*

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