Ia Form 8453 Ind – Fill Out and Use This PDF

2016 IA 8453-IND

Iowa Individual Income Tax Declaration for an e-File Return https://tax.iowa.gov

Your first name, middle initial, and last name					Spouse’s first name, middle initial, and last name
Your Social Security Number					Spouse’s Social Security Number
Home address, city, state, ZIP
						B. Spouse
Part I Tax Return Information						(filing status 3)					A. You or Joint
1.	Iowa Net Income (IA 1040, line 26 A & B)				1B			.00		1A		.00
2.	Total Tax (IA 1040, line 42 A & B)				2B			.00		2A		.00
3.	Iowa Income Tax Withheld (IA 1040, line 66 A & B)				3B			.00		3A		.00
4.	Amount to be Refunded (IA 1040, line 71)									4.		.00
5.	Total Amount Due (IA 1040, line 76)									5.		.00

Part II Declaration of Taxpayer (Be sure to keep a copy of the tax return)

Name of financial institution:

Routing Number

The first two digits must be 01 through 12 or 21 through 32.

Account Number

Type of Account:

Savings ☐

Checking ☐

Will this refund go to (or payment come from) an account outside the United States? Yes ☐ No ☐

Under penalties of perjury, I declare that I have examined the information on my electronic individual income tax return, including any schedules, attachments, and statements for tax year ending December 31, 2016 and certify to the best of my knowledge and belief, it is true, correct and complete. I further declare that the amounts in Part I above are the amounts shown on the copy of my electronic income tax return. I consent that my return, including accompanying schedules, attachments, and statements be sent to the Iowa Department of Revenue (IDR) through the Internal Revenue Service (IRS) by my Electronic Return Originator (ERO). In addition, by using software to prepare and transmit my return electronically, I consent to the disclosure to Iowa of all information pertaining to the transmission of my tax return electronically. I authorize IDR to inform my ERO and/or transmitter when my electronic return has been accepted. In the event that it is rejected, I authorize IDR to identify the reasons for rejection so that the return can be corrected and re-transmitted. If I have filed a balance due return, I understand that if IDR does not receive full and timely payment of my tax liability I will remain liable for the tax liability and all applicable penalties and interest. I consent that my refund be directly deposited as designated in Part II and declare that the information shown in Part II is correct. If the processing of my return, refund, or direct debit is delayed, I authorize IDR to disclose to my ERO and/or transmitter the reason(s) for the delay or the date the refund was sent. I understand that this declaration with required attachments must be forwarded upon request to the IDR.

Your SignatureDate:Spouse Signature. If a joint return, both must sign.Date

Part III Declaration of Electronic Return Originator (ERO) and Paid Preparer

I declare that I have reviewed the above taxpayer’s return and that entries on form IA 8453-IND are complete and correct to the best of my knowledge. If I am only a collector, I am not responsible for reviewing the return and only declare that this form accurately reflects the data on the return. I have obtained the taxpayer’s signature before submitting this return to the IRS. I have provided the taxpayer with a copy of all forms and information to be filed with IDR and have followed all other requirements described in the Iowa Modernized e-File (MeF) Information for e-File Providers publication. Original form IA 8453-IND should not be sent to IDR, but must instead be retained by the ERO for a period of three years from the date the return or the filing date, whichever is later, to which the IA 8453-IND relates was filed. I will make a copy available to IDR upon request. If I am a paid preparer, under penalties of perjury, I declare that I have examined the above taxpayer’s return and accompanying schedules, attachments, and statements, and to the best of my knowledge and belief, they are true, correct, and complete. I have based this declaration on all information available to me.

					Check if
ERO					also paid		Check if self-
Signature			Date		preparer ☐		employed ☐	ERO PTIN
Firm’s name (or yours if								FEIN
self-employed)
								Phone
Address and zip code
								Number (	)
Paid Preparer						Check if self-
Signature				Date		employed ☐		Preparer PTIN
Firm’s name (or yours if								FEIN
self-employed)
								Phone
Address and zip code
								Number (	)

41-011a (10/19/2016)