JOHN SMITH

Form 1040NR U.S. Nonresident Alien Income Tax Return OMB No. 1545-0074 Information about Form 1040NR and its separate instructions is at www.irs.gov/form1040nr. Department of the Treasury For the year January 1 December 31, 2013, or other tax year Internal Revenue Service beginning, and ending Your first name M.I. Last name Identifying number (see instructions) Please print or type Filing Status Check only one box. JOHN SMITH 123-45-6789 Present home address (number, street, and apt. no., or rural route). If you have a P.O. box, see instructions. Check if: X Individual 123 ANYWHERE STREET Estate or Trust City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions). LONDON A12 B23 Foreign country name Foreign province/state/county Foreign postal code United Kingdom (England, Northern Ireland, Scotland, and Wa 1 Single resident of Canada or Mexico or single U.S. national 4 Married resident of South Korea 2 X Other single nonresident alien 5 Other married nonresident alien 3 Married resident of Canada or Mexico or married U.S. national 6 Qualifying widow(er) with dependent child (see instructions) If you checked box 3 or 4 above, enter the information below. (i) Spouse's first name and initial (ii) Spouse's last name (iii) Spouse's identifying number Exemptions 7a X Yourself. If someone can claim you as a dependent, do not check box 7a....... Boxes checked b Spouse. Check box 7b only if you checked box 3 or 4 above and your spouse did not on 7a and 7b 1 have any U.S. gross income.......................... If more than four dependents, see instructions. No. of children on 7c who: c Dependents: (see instructions) (4) if qualifying (2) Dependent's (3) Dependent's Enter Dependents on "Ln 7c - Dependents" tab below. child for child tax identifying number relationship to you lived with you 0 (1) First name Last name credit (see instr.) did not live with you due to divorce or separation (see instructions) 0 Dependents on 7c not entered above 0 Add numbers d Total number of exemptions claimed....................... on lines above 1 Income 8 Wages, salaries, tips, etc. Attach Form(s) W-2.................. 8 8,197 Effectively 9a Taxable interest............................... 9a Connected b Tax-exempt interest. Do not include on line 9a.......... 9b With U.S. 10a Ordinary dividends.............................. 10a Trade/ b Qualified dividends (see instructions)............... 10b Business 11 Taxable refunds, credits, or offsets of state and local income taxes (see instructions).... 11 Attach Form(s) W-2, 1042-S, SSA-1042S, RRB-1042S, and 8288-A here. Also attach Form(s) 1099-R if tax was withheld. Adjusted Gross Income 12 Scholarship and fellowship grants. Attach Form(s) 1042-S or required statement (see instructions).. 12 13 Business income or (loss). Attach Schedule C or C-EZ (Form 1040)............. 13 14 Capital gain or (loss). Attach Schedule D (Form 1040) if required. If not required, check here 14 15 Other gains or (losses). Attach Form 4797.................... 15 16a IRA distributions...... 16a 16b Taxable amount (see instructions) 16b 17a Pensions and annuities.... 17a 17b Taxable amount (see instructions) 17b 18 Rental real estate, royalties, partnerships, trusts, etc. Attach Schedule E (Form 1040).... 18 19 Farm income or (loss). Attach Schedule F (Form 1040)................ 19 20 Unemployment compensation......................... 20 21 Other income. List type and amount (see instructions) 21 22 Total income exempt by a treaty from page 5, Schedule OI, Item L (1)(e)... 22 23 Combine the amounts in the far right column for lines 8 through 21. This is your total effectively connected income.......................... 23 8,197 24 Educator expenses (see instructions)............... 24 25 Health savings account deduction. Attach Form 8889........ 25 26 Moving expenses. Attach Form 3903.............. 26 27 Deductible part of self-employment tax. Attach Schedule SE (Form 1040).. 27 28 Self-employed SEP, SIMPLE, and qualified plans......... 28 29 Self-employed health insurance deduction (see instructions)...... 29 30 Penalty on early withdrawal of savings.............. 30 31 Scholarship and fellowship grants excluded............ 31 32 IRA deduction (see instructions)................. 32 33 Student loan interest deduction (see instructions).......... 33 34 Domestic production activities deduction. Attach Form 8903...... 34 35 Add lines 24 through 34............................ 35 36 Subtract line 35 from line 23. This is your adjusted gross income........... 36 8,197 For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see instructions. Form 1040NR (2013) HTA

Form 1040NR (2013) JOHN SMITH 123-45-6789 Page 2 Tax and Credits Other Taxes Payments Refund Direct deposit? See instructions. 37 Amount from line 36 (adjusted gross income).................... 37 8,197 38 Itemized deductions from page 3, Schedule A, line 15..................... 38 6,957 39 Subtract line 38 from line 37.......................... 39 1,240 40 Exemptions (see instructions)......................... 40 3,900 41 Taxable income. Subtract line 40 from line 39. If line 40 is more than line 39, enter -0-... 41 0 42 Tax (see instructions). Check if any tax is from: a Form(s) 8814 b Form 4972 42 43 Alternative minimum tax (see instructions). Attach Form 6251............. 43 44 Add lines 42 and 43............................. 44 45 Foreign tax credit. Attach Form 1116 if required......... 45 46 Credit for child and dependent care expenses. Attach Form 2441 46 47 Retirement savings contributions credit. Attach Form 8880..... 47 48 Child tax credit. Attach Schedule 8812, if required........ 48 49 Residential energy credits. Attach Form 5695.......... 49 50 Other credits from Form: a 3800 b 8801 c 50 51 Add lines 45 through 50. These are your total credits................ 51 52 Subtract line 51 from line 44. If line 51 is more than line 44, enter -0-......... 52 0 53 Tax on income not effectively connected with a U.S. trade or business from page 4, Schedule NEC, line 15... 53 54 Self-employment tax. Attach Schedule SE (Form 1040)................ 54 55 Unreported social security and Medicare tax from Form: a 4137 b 8919 55 56 Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required 56 57 Transportation tax (see instructions)........................ 57 58a Household employment taxes from Schedule H (Form 1040).............. 58a b First-time homebuyer credit repayment. Attach Form 5405 if required........... 58b 59 Taxes from: a Form 8959 b Instructions; enter code(s) 59 60 Add lines 52 through 59. This is your total tax.................. 60 0 61 Federal income tax withheld from: a Form(s) W-2 and 1099................... 61a b Form(s) 8805....................... 61b c Form(s) 8288-A...................... 61c d Form(s) 1042-S...................... 61d 62 2013 estimated tax payments and amount applied from 2012 return... 62 63 Additional child tax credit. Attach Schedule 8812........ 63 64 Amount paid with request for extension to file (see instructions)... 64 65 Excess social security and tier 1 RRTA tax withheld (see instructions)... 65 66 Credit for federal tax paid on fuels. Attach Form 4136....... 66 67 Credits from Form: a 2439 b Reserved c 8885 d 67 68 Credit for amount paid with Form 1040-C........... 68 69 Add lines 61a through 68. These are your total payments............. 69 0 70 If line 69 is more than line 60, subtract line 60 from line 69. This is the amount you overpaid.... 70 71 a Amount of line 70 you want refunded to you. If Form 8888 is attached, check here 71a b Routing number c Type: Checking Savings d Account number e If you want your refund check mailed to an address outside the United States not shown on page 1, enter it here. 72 Amount of line 70 you want applied to your 2014 estimated tax 72 Amount 73 Amount you owe. Subtract line 69 from line 60. For details on how to pay, see instructions... 73 0 You Owe 74 Estimated tax penalty (see instructions).............. 74 Third Party Designee Sign Here Keep a copy of this return for your records. Paid Preparer Use Only Do you want to allow another person to discuss this return with the IRS (see instructions)? Yes. Complete below. No Phone Personal identification Designee's name no. number (PIN) 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 belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. Your signature Date Your occupation in the United States If the IRS sent you an Identity Protection PIN, enter it here (see inst.) INTERN Print/Type preparer's name Preparer's signature Date PTIN Check if 3/3/2014 self-employed Firm's name Firm's EIN Firm's address Phone no. Form 1040NR (2013)

Form 1040NR (2013) JOHN SMITH 123-45-6789 Page 3 Schedule A Itemized Deductions (see instructions) 07 Taxes You Paid 1 State and local income taxes......................... 1...... 89....... Caution: If you made a gift and received a benefit in return, see instructions. Gifts to U.S. Charities 2 Gifts by cash or check. If you made any gift of $250 or more, see instructions................. 2........................ 3 Other than by cash or check. If you made any gift of $250 or more, see instructions. You must attach Form 8283 if the amount of your deduction is over $500...... 3........................ 4 Carryover from prior year................ 4....................... 5 Add lines 2 through 4............................. 5........ 0...... Casualty and Theft Losses 6 Casualty or theft loss(es). Attach Form 4684. See instructions............ 6............. Job 7 Unreimbursed employee expenses job travel, union dues, Expenses job education, etc. You must attach Form 2106 or Form and Certain 2106-EZ if required. See instructions Miscellaneous 2106EZ Filer Bus Exp $ 7,032 7 7,032 Deductions 8 Tax preparation fees................. 8........................ 9 Other expenses. See instructions for expenses to deduct here. List type and amount $ $ $ $ 9 10 Add lines 7 through 9................. 10..... 7,032................... 11 Enter the amount from Form 1040NR, line 37........ 11...... 8,197............................. 12 Multiply line 11 by 2% (.02)............... 12...... 164.................. Other Miscellaneous Deductions 13 Subtract line 12 from line 10. If line 12 is more than line 10, enter -0-......... 13..... 6,868........ 14 Other see instructions for expenses to deduct here. List type and amount Total 15 Is Form 1040NR, line 37, over the amount shown below for the filing status box you Itemized checked on page 1 of Form 1040NR: Deductions $300,000 if you checked box 6, $250,000 if you checked box 1 or 2, or $150,000 if you checked box 3, 4, or 5? X No. Your deduction is not limited. Add the amounts in the far right column for lines 1 through 14. Also enter this amount on Form 1040NR, line 38. 14 Yes. Your deduction may be limited. See the Itemized Deductions Worksheet in the instructions to figure the amount to enter here and on Form 1040NR, line 38. 15 6,957 Form 1040NR (2013)

Form 1040NR (2013) JOHN SMITH 123-45-6789 Page 4 Schedule NEC Tax on Income Not Effectively Connected With a U.S. Trade or Business (see instructions) Enter amount of income under the appropriate rate of tax (see instructions) Nature of income (d) Other (specify) (a) 10% (b) 15% (c) 30% 0% 0% 1 Dividends paid by: a U.S. corporations..................... 1a b Foreign corporations..................... 1b 2 Interest: a Mortgage......................... 2a b Paid by foreign corporations................. 2b c Other.......................... 2c 3 Industrial royalties (patents, trademarks, etc.).......... 3 4 Motion picture or T.V. copyright royalties............ 4 5 Other royalties (copyrights, recording, publishing, etc.)....... 5 6 Real property income and natural resources royalties........ 6 7 Pensions and annuities.................... 7 8 Social security benefits................... 8 9 Capital gain from line 18 below................ 9 10 Gambling Residents of Canada only. Enter net income in column (c). If zero or less, enter -0-. a Winnings b Losses 10c 0 11 Gambling winnings Residents of countries other than Canada Note. Losses not allowed................... 11 12 Other (specify) 12 13 Add lines 1a through 12 in columns (a) through (d)......... 13 0 0 0 0 0 14 Multiply line 13 by rate of tax at top of each column....... 14 0 0 0 0 0 15 Tax on income not effectively connected with a U.S. trade or business. Add columns (a) through (d) of line 14. Enter the total here and on Form 1040NR, line 53.................................................... 15 0 Capital Gains and Losses From Sales or Exchanges of Property Enter only the capital gains and losses from property sales or exchanges that are from sources within the United States and not effectively connected with a U.S. business. Do not include a gain or loss on disposing of a U.S. real property interest; report these gains and losses on Schedule D (Form 1040). 16 (a) Kind of property and description (if necessary, attach statement of descriptive details not shown below) (b) Date acquired (mo., day, yr.) (c) Date sold (mo., day, yr.) (d) Sales price (f) LOSS (g) GAIN (e) Cost or other If (e) is more If (d) is more basis than (d), subtract (d) than (e), subtract (e) from (e) from (d) Report property sales or exchanges that are effectively connected with a U.S. business on Schedule D (Form 1040), Form 4797, or both. Enter on Ln 16 - Input or Ln 16 - Detail tab 17 Add columns (f) and (g) of line 16............................ 17 ( 0 ) 0 18 Capital gain. Combine columns (f) and (g) of line 17. Enter the net gain here and on line 9 above (if a loss, enter -0-) 18 0 Form 1040NR (2013)

Form 1040NR (2013) JOHN SMITH 123-45-6789 Page 5 Schedule OI Other Information (see instructions) Answer all questions A Of what country or countries were you a citizen or national during the tax year? UK B In what country did you claim residence for tax purposes during the tax year? UK C Have you ever applied to be a green card holder (lawful permanent resident) of the United States?..... Yes X No D E Were you ever: 1. A U.S. citizen?..................................... Yes X No 2. A green card holder (lawful permanent resident) of the United States?............... Yes X No If you answer "Yes" to (1) or (2), see Pub. 519, chapter 4, for expatriation rules that apply to you. If you had a visa on the last day of the tax year, enter your visa type. If you did not have a visa, enter your U.S. immigration status on the last day of the tax year. J1 F Have you ever changed your visa type (nonimmigrant status) or U.S. immigration status?........ Yes X No If you answered "Yes," indicate the date and nature of the change. G List all dates you entered and left the United States during 2013 (see instructions). Note. If you are a resident of Canada or Mexico AND commute to work in the United States at frequent intervals, check the box for Canada or Mexico and skip to item H........... Canada Mexico Date entered United States Date departed United States Date entered United States Date departed United States mm/dd/yy mm/dd/yy mm/dd/yy mm/dd/yy 08/23/13 H Give number of days (including vacation, nonworkdays, and partial days) you were present in the United States during: 2011, 2012 131, and 2013 235. I Did you file a U.S. income tax return for any prior year?...................... X Yes No If "Yes," give the latest year and form number you filed... 2012 1040-NR J Are you filing a return for a trust?............................... Yes X No If "Yes," did the trust have a U.S. or foreign owner under the grantor trust rules, make a distribution or loan to a U.S. person, or receive a contribution from a U.S. person?..................... Yes No K Did you receive total compensation of $250,000 or more during the tax year?............. Yes X No If "Yes," did you use an alternative method to determine the source of this compensation?........ Yes No L Income Exempt from Tax If you are claiming exemption from income tax under a U.S. income tax treaty with a foreign country, complete (1) and (2) below. See Pub. 901 for more information on tax treaties. 1. Enter the name of the country, the applicable tax treaty article, the number of months in prior years you claimed the treaty benefit, and the amount of exempt income in the columns below. Attach Form 8833 if required (see instructions). (b) Tax treaty (c) Number of months (d) Amount of exempt (a) Country article claimed in prior tax years income in current tax year (e) Total. Enter this amount on Form 1040NR, line 22. Do not enter it on line 8 or line 12........ 0 2. Were you subject to tax in a foreign country on any of the income shown in 1(d) above?........ Yes No Form 1040NR (2013)

Form 2106-EZ Department of the Treasury Internal Revenue Service (99) Unreimbursed Employee Business Expenses Attach to Form 1040 or Form 1040NR. Information about Form 2106 and its separate instructions is available at www.irs.gov/form2106. OMB No. 1545-0074 Attachment Sequence No. Your name Occupation in which you incurred expenses Social security number JOHN SMITH INTERN 123-45-6789 You Can Use This Form Only if All of the Following Apply. You are an employee deducting ordinary and necessary expenses attributable to your job. An ordinary expense is one that is common and accepted in your field of trade, business, or profession. A necessary expense is one that is helpful and appropriate for your business. An expense does not have to be required to be considered necessary. You do not get reimbursed by your employer for any expenses (amounts your employer included in box 1 of your Form W-2 are not considered reimbursements for this purpose). If you are claiming vehicle expense, you are using the standard mileage rate for 2013. Caution: You can use the standard mileage rate for 2013 only if: (a) you owned the vehicle and used the standard mileage rate for the first year you placed the vehicle in service, or (b) you leased the vehicle and used the standard mileage rate for the portion of the lease period after 1997. Part I Figure Your Expenses 129A 1 Complete Part II. Multiply line 8a by 56.5 (.565). Enter the result here............ 1 0 2 Parking fees, tolls, and transportation, including train, bus, etc., that did not involve overnight travel or commuting to and from work..................... 2 1,650 3 Travel expense while away from home overnight, including lodging, airplane, car rental, etc. Do not include meals and entertainment........................ 3 4 Business expenses not included on lines 1 through 3. Do not include meals and entertainment................................... 4 5 Meals and entertainment expenses: $ 10,764 x 50% (.50). (Employees subject to Department of Transportation (DOT) hours of service limits: Multiply meal expenses incurred while away from home on business by 80% (.80) instead of 50%. For details, see instructions.).. 5 5,382 6 Total expenses. Add lines 1 through 5. Enter here and on Schedule A (Form 1040), line 21 (or on Schedule A (Form 1040NR), line 7). (Armed Forces reservists, fee-basis state or local government officials, qualified performing artists, and individuals with disabilities: See the instructions for special rules on where to enter this amount.)................ 6 7,032 Part II Information on Your Vehicle. Complete this part only if you are claiming vehicle expense on line 1. 7 When did you place your vehicle in service for business use? (month, day, year) 8 Of the total number of miles you drove your vehicle during 2013, enter the number of miles you used your vehicle for: a Business b Commuting (see instructions) c Other 9 Was your vehicle available for personal use during off-duty hours?................... Yes No 10 Do you (or your spouse) have another vehicle available for personal use?................ Yes No 11 a Do you have evidence to support your deduction?......................... Yes No b If "Yes," is the evidence written?................................ Yes No For Paperwork Reduction Act Notice, see your tax return instructions. Form 2106-EZ (2013) HTA

2013 New York State Department of Taxation and Finance Nonresident and Part-Year Resident Income Tax Return New York State New York City Yonkers IT-203 For the year January 1, 2013, through December 31, 2013, or fiscal year beginning... and ending... For help completing your return, see the instructions, Form IT-203-I. Your first name and middle initial Your last name (for a joint return, enter spouse's name on line below) Your date of birth (mm-dd-yyyy) Your social security number JOHN SMITH 01-01-1985 123-45-6789 Spouse's first name and middle initial Spouse's last name Spouse's date of birth (mm-dd-yyyy) Spouse's social security number 13 Mailing address (see instructions, page 13) (number and street or rural route) Apartment number New York State county of residence 123 ANYWHERE STREET NR City, village, or post office State ZIP code Country (if not United States) School district name LONDON UNITED KINGDOM (ENGLANDNR Taxpayer's permanent home address (see instr., pg 13) (no. and street or rural route) Apartment no. City, village, or post office School district code number State ZIP code Country (if not United States) Taxpayer's date of death Spouse's date of death Decedent information A Filing status (mark an X in one box): X Single F Enter your 2-character special condition code if applicable (see page 14)... E4 Married filing joint return (enter both spouses' social security numbers above) Married filing separate return (enter both spouses' social security numbers above) Head of household (with qualifying person) Qualifying widow(er) with dependent child If applicable, also enter your second 2-character special condition code... G New York State part-year residents (see page 15) Enter the date you moved into or out of NYS (mm-dd-yyyy)... On the last day of the tax year (mark an X in one box): B Did you itemize your deductions on 1) Lived in NYS... your 2013 federal income tax return?... Yes X No 2) Lived outside NYS; received income from C Can you be claimed as a dependent NYS sources during nonresident period... on another taxpayer's federal return?... Yes No X 3) Lived outside NYS; received no income from D Did you have a financial account NYS sources during nonresident period... located in a foreign country? (see pg 14)... Yes No X H New York State nonresidents (see page 15) E New York City part-year residents only (see page 14) Did you or your spouse maintain (1) Number of months you lived in NY City in 2013... living quarters in NYS in 2013?... Yes No X (2) Number of months your spouse lived (if Yes, complete Form IT-203-B) in NY City in 2013... I Dependent exemption information (see page 15) First name and middle initial Last name Relationship Social security number Date of birth (mm-dd-yyyy) If more than 7 dependents, mark an X in the box.

Page 2 of 4 IT-203 (2013) Enter your social security number 123-45-6789 Federal income and adjustments (see page 17) Federal amount Whole dollars only New York State amount Whole dollars only 1 Wages, salaries, tips, etc.... 1 8,197. 1 8,197. 2 Taxable interest income... 2 2 3 Ordinary dividends... 3 3 4 Taxable refunds, credits, or offsets of state and local income taxes (also enter on line 24)... 4 4 5 Alimony received... 5 5 6 Business income or loss (submit a copy of federal Sch. C or C-EZ, Form 1040)... 6 6 7 Capital gain or loss (if required, submit a copy of federal Sch. D, Form 1040)... 7 7 8 Other gains or losses (submit a copy of federal Form 4797)... 8 8 9 Taxable amount of IRA distributions. Beneficiaries: mark X in box 9 9 10 Taxable amount of pensions/annuities. Beneficiaries: mark X in box 10 10 11 Rental real estate, royalties, partnerships, S corporations, trusts, etc. (submit a copy of federal Schedule E, Form 1040).. 11 11 12 Rental real estate included in line 11 (federal amount). 12 13 Farm income or loss (submit a copy of federal Sch. F, Form 1040)... 13 13 14 Unemployment compensation... 14 14 15 Taxable amount of social security benefits (also enter on line 26)... 15 15 16 Other income (see page 22) Identify: 16 16 17 Add lines 1 through 11 and 13 through 16... 17 8,197. 17 8,197. 18 Total federal adjustments to income (see page 22) Identify: 18 18 19 Federal adjusted gross income (subtract line 18 from line 17) 19 8,197. 19 8,197. New York additions (see page 24) 20 Interest income on state and local bonds (but not those of New York State or its localities)... 20 20 21 Public employee 414(h) retirement contributions... 21 21 22 Other (see page 24) Identify: 22 22 23 Add lines 19 through 22... 23 8,197. 23 8,197. New York subtractions (see page 28) 24 Taxable refunds, credits, or offsets of state and local income taxes (from line 4)... 24 24 25 Pensions of NYS and local governments and the federal government (see page 28)... 25 25 26 Taxable amount of social security benefits (from line 15)... 26 26 27 Interest income on U.S. government bonds... 27 27 28 Pension and annuity income exclusion... 28 28 29 Other (see page 29) Identify: 29 29 30 Add lines 24 through 29... 30 30 31 New York adjusted gross income (subtract line 30 from line 23)... 31 8,197. 31 8,197. 32 Enter the amount from line 31, Federal amount column... 32 8,197. Standard deduction or itemized deduction (see page 33) 33 Enter your standard deduction (table on page 33) or your itemized deduction (from Form IT-203-D). Mark an X in the appropriate box:... X Standard or Itemized 33 7,700. 34 Subtract line 33 from line 32 (if line 33 is more than line 32, leave blank)... 34 497. 35 Dependent exemptions (not the same as total federal exemptions; see page 33)... 35 36 New York taxable income (subtract line 35 from line 34)... 36 497.

Name(s) as shown on page 1 Enter your social security number IT-203 (2013) Page 3 of 4 JOHN SMITH 123-45-6789 Tax computation, credits, and other taxes (see page 34) 37 New York taxable income (from line 36 on page 2)... 37 497. 38 New York State tax on line 37 amount (see page 34 and Tax computation on pages 66, 67, and 68).. 38 19. 39 New York State household credit (page 34, table 1, 2, or 3)... 39 45. 40 Subtract line 39 from line 38 (if line 39 is more than line 38, leave blank)... 40 41 New York State child and dependent care credit (see page 35)... 41 42 Subtract line 41 from line 40 (if line 41 is more than line 40, leave blank)... 42 43 New York State earned income credit (see page 35)... 43 44 Base tax (subtract line 43 from line 42; if line 43 is more than line 42, leave blank)... 44 45 Income percentage (see page 35) New York State amount from line 31 Federal amount from line 31 Round result to 4 decimal places 8,197. 8,197. = 45 1.0000 46 Allocated New York State tax (multiply line 44 by the decimal on line 45)... 46 47 New York State nonrefundable credits (Form IT-203-ATT, line 8)... 47 48 Subtract line 47 from line 46 (if line 47 is more than line 46, leave blank)... 48 49 Net other New York State taxes (Form IT-203-ATT, line 33)... 49 50 Total New York State taxes (add lines 48 and 49)... 50 New York City and Yonkers taxes and credits 51 Part-year New York City resident tax (Form IT-360.1)... 51 See instructions on pages 35 52 New York City minimum income tax (Form IT-220)... 52 and 36 to compute New York 52a Add lines 51 and 52... 52a 52b Part-year resident nonrefundable New York City City and Yonkers taxes, credits, and surcharges. child and dependent care credit... 52b 52c Subtract line 52b from 52a... 52c 53 Yonkers nonresident earnings tax (Form Y-203)... 53 54 Part-year Yonkers resident income tax surcharge (Form IT-360.1)... 54 55 Total New York City and Yonkers taxes (add lines 52c, 53, and 54)... 55 56 Sales or use tax (See the instructions on page 36. Do not leave line 56 blank.)... 56 0. Voluntary contributions (see page 37) 57a Return a Gift to Wildlife... 57a 57b Missing/Exploited Children Fund... 57b 57c Breast Cancer Research Fund... 57c 57d Alzheimer's Fund... 57d 57e Olympic Fund ($2 or $4)... 57e 57f Prostate Cancer Research Fund... 57f 57g 9/11 Memorial... 57g 57h Volunteer Firefighting & EMS Recruitment Fund... 57h 57i Teen Health Education... 57i 57j Veterans Remembrance... 57j 57 Total voluntary contributions (add lines 57a through 57j)... 57 58 Total New York State, New York City, and Yonkers taxes, sales or use tax, and voluntary contributions (add lines 50, 55, 56, and 57)... 58

Page 4 of 4 IT-203 (2013) Enter your social security number 123-45-6789 59 Enter amount from line 58... 59 Payments and refundable credits (see page 38) 60 Part-year NYC school tax credit (also complete E on front; see page 38)... 60 61 Other refundable credits (Form IT-203-ATT, line 17)... 61 Submit your wage and tax 62 Total New York State tax withheld... 62 89. statements with your return 63 Total New York City tax withheld... 63 (see page 38). 64 Total Yonkers tax withheld... 64 65 Total estimated tax payments/amount paid with Form IT-370... 65 66 Total payments and refundable credits (add lines 60 through 65)... 66 89. Your refund, amount you owe, and account information (see pages 39 through 42) 67 Amount overpaid (if line 66 is more than line 59, subtract line 59 from line 66)... 67 89. 68 Amount of line 67 to be refunded direct debit paper Mark one refund choice: X deposit (fill in line 73) - or - card - or - check... 68 89. See pages 39 and 40 for 69 Amount of line 67 that you want applied to your 2014 estimated tax (see instructions)... 69 70 Amount you owe (if line 66 is less than line 59, subtract line 66 from line 59). To pay by electronic information about your three refund choices. See page 40 for payment funds withdrawal, mark an X in the box and fill in lines 73 and 74. If you pay by check options. or money order you must complete Form IT-201-V and mail it with your return.... 70 71 Estimated tax penalty (include this amount on line 70, or reduce the overpayment on line 67; see page 40)... 71 72 Other penalties and interest (see page 40)... 72 See page 43 for the proper assembly of your return. 73 Account information for direct deposit or electronic funds withdrawal (see page 41). If the funds for your payment (or refund) would come from (or go to) an account outside the U.S., mark an X in this box (see pg. 41) 73a Account type: X Personal checking - or - Personal savings - or - Business checking - or - Business savings 73b Routing number 021000021 73c Account number 2345678 74 Electronic funds withdrawal (see page 41)... Date Amount Third-party Print designee's name Designee's phone number Personal identification designee? (see instr.) number (PIN) Yes No E-mail: Date Paid preparer must complete (see instr.) 03-03-2014 Preparer's signature Preparer's NYTPRIN Your signature Taxpayer(s) must sign here Firm's name (or yours, if self-employed) Preparer's PTIN or SSN Your occupation INTERN Address Employer identification number Spouse's signature and occupation (if joint return) Mark an X if self-employed E-mail: E-mail: Date Daytime phone number See instructions for where to mail your return.