Michigan Department of Treasury

**** (Rev. **-**)

* * ,********* ,***** **[ 'HFODUDWLRQ IRU H OH 0 Issued under authority of Public Act 284 of 1964, as amended. 127 R QRW VHQG 0 WR WKH 0LFKLJDQ 'HSDUWPHQW RI 7UHDVXU\ XQOHVV UHTXHVWHG WR GR VR 1. Filer’s First Name M.I. Last Name 2. Filer’s Full Social Security No. (Example: ***-**-****) If a Joint Return, Spouse’s First Name M.I. Last Name 3. Spouse’s Full Social Security No. (Example: ***-**-****) Home Address (Number, Street, or P.O. Box)

City or Town State ZIP Code

3$57 7$; 5(7851 ,1)250$7,21

The taxpayer should obtain and keep a copy of the return.

)RUP 0 Individual Income Tax Return

4. Total federal adjusted gross income from line 10 4. 00 5. Total Michigan income tax from line 20 5. 00 6. Michigan tax withheld from line 29 6. 00 7. Tax due from line 33 7. 00 8. Refund from line 36 8. 00

)RUP 0 5 Homestead Property Tax Credit Claim 9. Homestead Property Tax Credit from line 44 9. 00

)RUP 0 5 Home Heating Credit Claim

10. Home Heating Credit Claim from line 44 10. 00

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11. Adjusted Gross Income or Wages from Form 5118, line 9, Form 5119, line 9, or Form 5120, line 10 (Column A) 11. 00 12. Tax Due from Form 5118, line 22e, Form 5119, line 24e, or Form 5120, line 41e 12. 00 13. Refund from Form 5118, line 25, Form 5119, line 27, or Form 5120, line 44 13. 00 PART 2: DECLARATION AND E-FILE AUTHORIZATION

Under penalties of perjury, I declare that I have examined this return including any accompanying statements and schedules and, to the best of my knowledge and belief, it is true, correct, and complete. The tax return information in Part 1 agrees with the amounts on the corresponding lines of my Michigan tax return. I consent to allow my Intermediate Service Provider, transmitter or Electronic Return Originator (ERO) to send my return to IRS and subsequently by the IRS to the Michigan Department of Treasury and to receive an acknowledgment of receipt or reason for rejection of the transmission.

Filer’s Signature Date Spouse’s Signature Date

3$57 7521,& 5(7851 25,*,1$725 (52 $1' 35(3$5(5 5$7,21 I declare that the information contained in this electronic tax return is the information furnished to me by the taxpayer. If the taxpayer furnished me a completed tax return, I declare that the information contained in this electronic tax return is identical to that contained in the return provided by the taxpayer. If the furnished return was signed by a paid preparer, I declare I have entered the paid preparer’s identifying information in the appropriate portion of this electronic return. If I am the paid preparer, under the penalties of perjury I declare that I have examined this electronic return, and to the best of my knowledge and belief, it is true, correct, and complete. This declaration is based on all information of which I have any knowledge.

ERO or Preparer Signature Date ERO is (check all that apply) Preparer Self-Employed

Firm Name (or name of ERO if self-employed) FEIN or PTIN Firm’s Address (Street, City, State, ZIP Code)

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JESSICA I MARKLEY

13250 NJENNINGS RD

CLIO MI 48420-

3037

129

143

Michigan Department of Treasury (Rev. 07-17), Page 1 of 2 Issued under authority of Public Act 281 of 1967, as amended. 2017 MICHIGAN Individual Income Tax Return MI-1040 Amended Return Return is due April 17, 2018. (Include Schedule AMD) 1. Filer’s First Name M.I. Last Name 2. Filer’s Full Social Security No. (Example: ***-**-****) If a Joint Return, Spouse’s First Name M.I. Last Name 3. Spouse’s Full Social Security No. (Example: ***-**-****) Home Address (Number, Street, or P.O. Box)

City or Town State ZIP Code 4. School District Code (5 digits – see page 60) 5. STATE CAMPAIGN FUND 6. FARMERS, FISHERMEN, OR SEAFARERS Check if you (and/or your spouse, if

filing a joint return) want $3 of your taxes

to go to this fund. This will not increase

your tax or reduce your refund.

a. Filer

Check this box if 2/3 of your income is from farming, b. Spouse fishing, or seafaring.

7. 2017 FILING STATUS. Check one. 8. 2017 RESIDENCY STATUS. Check all that apply. a. Single * If you check box “c,” complete

line 3 and enter spouse’s full name

below:

a. Resident

* If you check box “b” or

“c,” you must complete

and include Schedule

NR.

b. Married filing jointly b. Nonresident *

c. Married filing separately* c. Part-Year Resident * 9. EXEMPTIONS. NOTE: If someone else can claim you as a dependent, check box 9d, enter 0 on line 9a and enter $1,500 on line 9d (see instr.). a. Number of exemptions claimed on 2017 federal return 9a. x $4,000 9a. 00 b. Number of individuals who qualify for one of the following special exemptions: deaf, blind, hemiplegic, paraplegic, quadriplegic, or totally and permanently disabled 9b. x $2,600 9b. 00 c. Number of qualified disabled veterans 9c. x $400 9c. 00 d. Claimed as dependent, see line 9 NOTE above 9d. 9d. 00 e. Add lines 9a, 9b, 9c and 9d. Enter here and on line 15 9e. 00 10. Adjusted Gross Income from your U.S. Forms 1040, 1040A, 1040EZ or 1040NR (see instructions) 10. 00 11. Additions from Schedule 1, line 9. Include Schedule 1 11. 00 12. Total. Add lines 10 and 11 12. 00 13. Subtractions from Schedule 1, line 27. Include Schedule 1 13. 00 14. Income subject to tax. Subtract line 13 from line 12. If line 13 is greater than line 12, enter “0” 14. 00 15. Exemption allowance. Enter amount from line 9e or Schedule NR, line 19 15. 00 16. Taxable income. Subtract line 15 from line 14. If line 15 is greater than line 14, enter “0” 16. 00 17. Tax. Multiply line 16 by 4.25% (0.0425) 17. 00 NON-REFUNDABLE CREDITS AMOUNT CREDIT

18. Income Tax Imposed by government units outside Michigan. Include a copy of the return (see instructions 18a. 00 18b. 00 19. Michigan Historic Preservation Tax Credit carryforward and/or Small Business Investment Tax Credit (see instructions) 19a. 00 19b. 00 20. Income Tax. Subtract the sum of lines 18b and 19b from line 17. If the sum of lines 18b and 19b is greater than line 17, enter “0” 20. 00

+103*-****-**-** 27 5 Continue on page 2. This form cannot be processed if page 2 is not completed and included. ***-**-****

JESSICA I MARKLEY

13250 NJENNINGS RD

CLIO MI 48420- 25150

X X

1 4000

4000

3037

3037

3037

4000

2017 MI-1040, Page 2 of 2

Filer’s Full Social Security Number

21. Enter amount of Income Tax from line 20. 21. 00 22. Voluntary Contributions from Form 4642, line 7. Include Form 4642 22. 00 23. USE TAX. Use tax due on Internet, mail order or other out-of-state purchases from Worksheet 1 (see instructions) 23. 00 24. Total Tax Liability. Add lines 21, 22 and 23 24. 00 REFUNDABLE CREDITS AND PAYMENTS

25. Property Tax Credit. Include MI-1040CR or MI-1040CR-2 25. 00 26. Farmland Preservation Tax Credit. Include MI-1040CR-5 26. 00 FEDERAL MICHIGAN

27. Earned Income Tax Credit. Multiply line 27a by 6% (0.06) and enter result on line 27b. 27a. 00 27b. 00 28. Michigan Historic Preservation Tax Credit (refundable). Include Form 3581. 28. 00 29. Michigan tax withheld from Schedule W, line 7. Include Schedule W (do not submit W-2s) 29. 00 30. Estimated tax, extension payments and 2016 credit forward 30. 00 31. 2017 AMENDED RETURNS ONLY. Taxpayers completing an original 2017 return should skip to line 32. Amended returns must include Schedule AMD (see instructions). 31c. 00

If you had a refund and/or credit forward on the original return, check box 31a and enter this amount as a 31a. negative number on line 31c.

If you paid with the original return, check box 31b and enter the amount paid with the original return, plus 31b. any additional tax paid after filing, as a positive number on line 31c. Do not include interest or penalty. 32. Total refundable credits and payments. Add lines 25, 26, 27b, 28, 29, 30 and 31c 32. 00 REFUND OR TAX DUE

33. If line 32 is less than line 24, subtract line 32 from line 24. If applicable, see instructions. Include interest 00 and penalty 00 YOU OWE 33. 00 34. Overpayment. If line 32 is greater than line 24, subtract line 24 from line 32 34. 00 35. Credit Forward. Amount of line 34 to be credited to your 2018 estimated tax for your 2018 tax return ... 35. 00 36. Subtract line 35 from line 34. REFUND 36. 00 DIRECT DEPOSIT

Deposit your refund directly to your financial

institution! See instructions and complete a, b

and c.

a. Routing Transit Number b. Account Number c. Type of Account 1. Checking 2. Savings

Deceased Taxpayer. If Filer and/or Spouse died after December 31, 2016, enter dates below. ENTER DATE OF DEATH ONLY. Example: 04-15-2017 (MM-DD-YYYY) Preparer Certification. I declare under penalty of perjury that this return is based on all information of which I have any knowledge. Filer Spouse

Preparer’s PTIN, FEIN or SSN

Taxpayer Certification. I declare under penalty of perjury that the information in this return and attachments is true and complete to the best of my knowledge. Preparer’s Name (print or type)

Filer’s Signature Date Preparer’s Business Name, Address and Telephone Number Spouse’s Signature Date

By checking this box, I authorize Treasury to discuss my return with my preparer. Refund, credit, or zero returns. Mail your return to: Michigan Department of Treasury, Lansing, MI 48956 Pay amount on line 33 (see instructions). Mail your check and return to: Michigan Department of Treasury, Lansing, MI 48929

+103*-****-**-** 27 3

***-**-****

231 14

129

143

143

143

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Michigan Department of Treasury (Rev. 04-17), Page 1 of 2 Schedule W 2017 MICHIGAN Withholding Tax Schedule

Issued under authority of Public Act 281 of 1967, as amended. Attachment 13

INSTRUCTIONS: If you had Michigan income tax withheld in 2017, you must complete a Withholding Tax Schedule (Schedule W) to claim the withholding on your Individual Income Tax Return 0 OLQH 5HSRUW PLOLWDU\ SD\ LQ 7DEOH DQG PLOLWDU\ UHWLUHPHQW EHQH WV DQG WD[DEOH UDLOURDG UHWLUHPHQW EHQH WV LQ 7DEOH HYHQ LI QR 0LFKLJDQ WD[ ZDV ZLWKKHOG ,QFOXGH \RXU FRPSOHWHG 6FKHGXOH : ZLWK )RUP 0 ZKHUH applicable. See complete instructions on page 2 of this form. If you need additional space, include another Schedule W.

LOHU V )LUVW 1DPH M.I. Last Name LOHU V )XOO 6RFLDO 6HFXULW\ 1R ([DPSOH,I D -RLQW 5HWXUQ 6SRXVH V )LUVW 1DPH M.I. Last Name 6SRXVH V )XOO 6RFLDO 6HFXULW\ 1R ([DPSOH TABLE 1: MICHIGAN TAX WITHHELD OR MILITARY PAY REPORTED ON W-2, W-2G or CORRECTED W-2 FORMS AB C DE

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Filer or Spouse

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Box 1 Wages, tips,

other compensation

Box 17 Michigan

income tax withheld

00 00

00 00

00 00

00 00

00 00

00 00

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AB C DE

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Filer or Spouse

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Taxable pension distribution,

misc. income, etc. (see inst.)

Michigan income

tax withheld

00 00

00 00

00 00

00 00

00 00

00 00

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SUBTOTAL QWHU WRWDO RI 7DEOH FROXPQ ( 00

+103*-****-**-** 27 6 Continue on page 2.

JESSICA I MARKLEY ***-**-****

129

X 381950409 T&T SHEROSKI NO 3 INC 3037 129

2017 Schedule W, Page 2 of 2

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TABLE 3: MICHIGAN FLOW-THROUGH WITHHOLDING

ABC

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tax withheld

00

00

00

00

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(QWHU 7DEOH 6XEWRWDO IURP DGGLWLRQDO Schedule W forms (if applicable) 00 6. SUBTOTAL. (QWHU WRWDO RI 7DEOH FROXPQ & 6. 00 7. TOTAL GG OLQHV DQG QWHU KHUH DQG FDUU\ WR 0 OLQH 7. 00 Note: If line 6 does not apply, only submit page 1 of the Schedule W with your return.

+

Instructions for Schedule W

Withholding Tax Schedule

Schedule W is designed to report State of Michigan income tax withholding. Schedule W enables us to process your LQGLYLGXDO LQFRPH WD[ UHWXUQ PRUH HI FLHQWO\

Include the completed Schedule W with your return. An attachment number is listed in the upper right corner to help you assemble your forms in the correct order behind your Individual Income Tax Return (MI-1040).

If a Schedule W is not included when required, the processing of your return will be delayed. Do not submit W-2 and/or 1099 forms with your return.,I \RX DUH OLQJ DQ DPHQGHG UHWXUQ EHFDXVH \RX UHFHLYHG a corrected W-2 you must complete a Schedule W. Keep copies of your W-2s with your tax records for six years and have them available if requested by the Department of Treasury.

Michigan Residents. If you paid income tax to a

governmental unit outside of Michigan, see instructions for MI-1040, line 18.

Flow-Through Withholding. Complete Table 3 and report 0LFKLJDQ ÀRZ WKURXJK ZLWKKROGLQJ RQ 0 OLQH R QRW FODLP ÀRZ WKURXJK ZLWKKROGLQJ DV DQ HVWLPDWHG SD\PHQW Completing the Withholding Tables

Lines not listed are explained on the form.

Complete the withholding tables using information

IURP \RXU DQG 0 IRUPV DQG DQ\ RWKHU documents that report Michigan tax withheld. If you need additional space, include another Schedule W.

Table 1 Column D: Enter wages, tips, and other

compensation from W-2 forms from which Michigan tax was withheld. Exception: Enter military pay even if no Michigan tax was withheld.

Table 2 Column D: Enter unemployment compensation, taxable pension from federal return, and any other taxable LQFRPH IURP DQ IRUPV IURP ZKLFK 0LFKLJDQ WD[ ZDV withheld. Exception: (QWHU PLOLWDU\ UHWLUHPHQW EHQH WV DQG UDLOURDG UHWLUHPHQW EHQH WV IURP 5 55 DQG RU 55 5 IRUPV HYHQ LI QR 0LFKLJDQ WD[ ZDV ZLWKKHOG Table 3: 5HSRUW 0LFKLJDQ IORZ WKURXJK LQIRUPDWLRQ SURYLGHG WR \RX E\ WKH ÀRZ WKURXJK HQWLW\ This form may EH OHG ZLWKRXW SDJH LI \RX DUH QRW FODLPLQJ )ORZ 7KURXJK

:LWKKROGLQJ LQ 7DEOH I RQO\ SDJH QHHGV WR EH OHG DGG OLQHV DQG DQG FDUU\ WKH WRWDO WR )RUP 0 OLQH Line 7: Total. Enter total of line 4 from Table 1, line 5 from Table 2, and line 6 from Table 3 and carry total to Form 0 OLQH

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129

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