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2016 FORM IRA Page 1
Delaware Special Tax Computation DONOTWRITEORSTAPLEINTHISAREA
Individual Retirement Account Distribution
LASTNAME(S)ASSHOWNONRETURN YOURFIRSTNAME SPOUSE’SFIRSTNAME YOURSOCIALSECURITYNUMBER
PRESENTHOMEADDRESS SPOUSE’SSOCIALSECURITYNUMBER
CITY STATE ZIPCODE ColumnA ColumnB
(Spouseiffilingstatus4only) (Allotherfilingstatuses)
1. EntertotalIRAcontributionsallowedasadeductionforfederalpurposes,butdisallowedforDelaware
purposesforalltaxableyears..................................................................................................................... 1
2. EntertotalIRAcontributionsallowedasadeductionforfederalpurposesforalltaxable
years.......................................................................................................................................................... 2
3. EntertotaldistributionsofprincipleinallyearsforwhichaFORMIRAhasnotbeen(andwillnotbe)
filed............................................................................................................................................................ 3
4. SubtractLine3fromLine2andenterthedifferencehere. IfLine3isgreaterthanLine2,enter“0"
hereandonLine9ofthisform................................................................................................................. 4
5. EntertotalIRAdistributionfromBox2ofForm1099pertainingtothisdistribution................................... 5
6. DivideLine1byLine4. Roundtothenearesttenthofapercent. (Forexample.7526to.753). If
greaterthan1.0,enter1............................................................................................................................ 6
7. MultiplyLine5byLine6............................................................................................................................ 7
8. AddalldistributionsexcludedinprioryearswhereaFormIRAhasbeenfiled. (TotalofLines10onall
prioryearFormsIRA)................................................................................................................................ 8
9. SubtractLine8fromLine1,andenterhere(butnotlessthan0).............................................................. 9
10. EnterthelesserofLine7orLine9. (ThisistheportionofIRAdistributiontobeexcludedfrom
DelawareTaxableIncome)........................................................................................................................ 10
11. EnterDelawareTaxableIncomefromForm200-01,Line5orForm200-02,Line41............................... 11
12. SubtractLine10fromLine11. ThisisyourDelawareAdjustedTaxableIncome..................................... 12
13. ComputeyouradjustedDelawaretaxliabilityusingthetaxtableifLine12isunder$60,000.,orthetax
ratescheduleifLine12is$60,000orover................................................................................................ 13
14. EntertheDelawaretaxliabilityfromForm200-01,Line8orForm200-02,Line42.................................. 14
15. SubtractLine13fromLine14. Thisisyouroverpayment........................................................................ 15
16. AddLine15,ColumnsAandB. Thisistheamounttoberefunded......................................................... 16
Underpenaltiesofperjury,IdeclarethatIhaveexaminedthisreturn,includingaccompanyingschedulesandstatements,andbelieveitistrue,
correctandcomplete. Ifpreparedbyapersonotherthanthetaxpayer,hisdeclarationisbasedonallinformationofwhichhehasanyknowledge.
Your Signature Date SignatureofPaidPreparer Date
Spouse's Signature (if filing joint or combined return) Date Address
HomePhone Business Phone City State Zip
E-MailAddress EIN, SSN OR PTIN Business Phone E-MailAddress
Mailcompletedformto: DivisionofRevenue,P.O.Box508,Wilmington,Delaware19899-0508
*DF21016019999*
(Rev. 1020//15) DF21016019999
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