• Amended Return - enter code:

(see instructions) Full-yr Resident? Your Social Security No. Your first name

Your last name

Y/N Spouse’s Soc. Sec. No. Spouse’s first name Spouse's last name

Address

Telephone number

City State ZIP+4 Foreign country (if not U.S.) 1 Filing Status - enter code • 2 Qualifying Dependents 3 Election Campaign Fund 1 = Single a Dependents age 16 and under

Does not increase your tax or reduce your refund. • 2 = Married filing jointly b Other dependents Enter the code for the Yourself Spouse 3 = Married filing separately c Total (add lines a and b) party of your choice. •

• 4 = Head of household

See instructions for 5 = Qualifying widow(er) Dependents must be claimed for the child tax code letters or go to incometax.utah.gov/elect. If using code 2 or 3, enter spouse’s name and SSN above credit on your federal return. See instructions. If no contribution, enter N. 4 Federal adjusted gross income from federal return

• 4 5 Additions to income from TC-40A, Part 1 (attach TC-40A, page 1)

• 5 6 Total income - add line 4 and line 5

6 7 State tax refund included on federal form 1040, Schedule 1, line 1 (if any)

• 7 8 Subtractions from income from TC-40A, Part 2 (attach TC-40A, page 1)

• 8 9 Utah taxable income (loss) - subtract the sum of lines 7 and 8 from line 6

• 9 10 Utah tax - multiply line 9 by 4.95% (.0495) (not less than zero)

• 10 11 Utah personal exemption (multiply line 2c by $1,750)

• 11

12 Federal standard or itemized deductions

• 12 13 Add line 11 and line 12

13 14 State income tax included in federal itemized deductions

• 14 15 Subtract line 14 from line 13

15 16 Initial credit before phase-out - multiply line 15 by 6% (.06)

• 16 17 Enter: $15,095 (if single or married filing separately); $22,643 (if head

• 17

of household); or $30,190 (if married filing jointly or qualifying widower) 18 Income subject to phase-out - subtract line 17 from line 9 (not less than zero) 18 19 Phase-out amount - multiply line 18 by 1.3% (.013)

• 19 20 Taxpayer tax credit - subtract line 19 from line 16 (not less than zero)

• 20 21 If you are a qualified exempt taxpayer, enter “X” (complete worksheet in instr.) • 21 22 Utah income tax - subtract line 20 from line 10 (not less than zero)

• 22 USTC ORIGINAL FORM Utah State Tax Commission Utah Individual Income Tax Return All State Income Tax Dollars Fund Education 2021 TC-40 40101 If deceased, complete page 3, Part 1 Electronic filing is quick, easy and free, and will speed up your refund. To learn more, go to tap.utah.gov .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 9998

Clear form

23 Enter tax from TC-40, page 1, line 22

23 24 Apportionable nonrefundable credits from TC-40A, Part 3 (attach TC-40A, page 1)

• 24 25 Full-year resident, subtract line 24 from line 23 (not less than zero)

• 25

Non or Part-year resident, complete and enter the UTAH TAX from TC-40B, line 41 26 Nonapportionable nonrefundable credits from TC-40A, Part 4 (attach TC-40A, page 1)

• 26 27 Subtract line 26 from line 25 (not less than zero)

27 28 Voluntary contributions from TC-40, page 3, Part 4 (attach TC-40, page 3)

• 28 29 AMENDED RETURN ONLY - previous refund

• 29 30 Recapture of low-income housing credit

• 30 31 Utah use tax

• 31 32 Total tax, use tax and additions to tax (add lines 27 through 31)

32 33 Utah income tax withheld shown on TC-40W, Part 1 (attach TC-40W, page 1)

• 33 34 Credit for Utah income taxes prepaid from TC-546 and 2020 refund applied to 2021

• 34 35 Pass-through entity withholding tax shown on TC-40W, Part 3 (attach TC-40W, page 2)

• 35 36 Mineral production withholding tax shown on TC-40W, Part 2 (attach TC-40W, page 2)

• 36 37 AMENDED RETURN ONLY - previous payments

• 37 38 Refundable credits from TC-40A, Part 5 (attach TC-40A, page 2)

• 38 39 Total withholding and refundable credits - add lines 33 through 38

39 40 TAX DUE - subtract line 39 from line 32 (not less than zero)

• 40 41 Penalty and interest (see instructions)

41 42 TOTAL DUE - PAY THIS AMOUNT - add line 40 and line 41

• 42 43 REFUND - subtract line 32 from line 39 (not less than zero)

• 43 44 Voluntary subtractions from refund (not greater than line 43)

• 44

Enter the total from page 3, Part 5 45 DIRECT DEPOSIT YOUR REMAINING REFUND - provide account information (see instructions for foreign accounts) checking savings

• Routing number • Account number

Account type: • • Under penalties of perjury, I declare to the best of my knowledge and belief, this return and accompanying schedules are true, correct and complete. SIGN Your signature

Date

Spouse’s signature (if filing jointly)

Date HERE Third Party Name of designee (if any) you authorize to discuss this return

Designee’s telephone number Designee PIN Designee

•

Preparer’s signature

Date

Preparer’s telephone number Preparer’s PTIN Paid

• Preparer’s Firm’s name

Preparer’s EIN Section and address

• Attach TC-40 page 3 if you: are filing for a deceased taxpayer, are filing a fiscal year return, filed IRS form 8886, are making voluntary contributions, want to deposit into a my529 account, want to apply all/part of your refund to next year’s taxes, want to direct deposit to a foreign account, or no longer qualify for a homeowner’s exemption. USTC ORIGINAL FORM 40102 Utah Individual Income Tax Return (continued) TC-40 Pg. 2 SSN Last name 2021 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00

Part 1 - Deceased Taxpayer Information

If the taxpayer shown on page 1 is deceased, enter the date of death here: •

mm/dd/yy

If the spouse shown on page 1 is deceased, enter the date of death here: •

mm/dd/yy

If you are claiming a refund for a deceased taxpayer and are not the surviving spouse, enter “X”: •

You must complete and attach form TC-131 to the return. Part 2 - Fiscal Year Filer

If filing a fiscal year return (a year other than January 1 through December 31), enter the fiscal year end (mm/yy) •

See instructions. mm/yy Part 3 - Federal Form 8886 filed

If you filed federal form 8886, Reportable Transaction Disclosure Statement, enter “X”: •

Get form and instructions at irs.gov. Part 4 - Voluntary Contributions (write the code and amount of each voluntary contribution)

See explanation of each contribution at incometax.utah.gov/contributions and/or the TC-40 instructions

Sch Dist

02 Pamela Atkinson Homeless Account Code Amount Code

03 Kurt Oscarson Children’s Organ Transplant Account

05 School District and Nonprofit School District Foundation - enter school district code •

See instructions for school district codes, or get codes at

incometax.utah.gov/contributions/school-districts •

15 Clean Air Fund

16 Governor’s Suicide Prevention Fund •

• Total voluntary contributions (enter the total here and on TC-40, page 2, line 28): Part 5 - Voluntary Subtractions from Refund

1. Enter the amount of your refund you want deposited into your my529 account(s): • 1

See instructions. Also see my529.org, or call 1-800-418-2551.

2. Enter the amount of your refund you want applied to your 2022 taxes: • 2

Total voluntary subtractions (enter the total here and on TC-40, page 2, line 44):

May not be greater than the amount on line 43. Part 6 - Direct Deposit to Foreign Account

If you choose to direct deposit your refund to an account outside the United States and its territories, enter “X”: •

The Tax Commission cannot transfer a refund to an account outside the United States and its territories.

By checking this box, your refund will not be direct deposited but will be sent to you by check. Part 7 - Property Owner’s Residential Exemption Termination Declaration

If you are a Utah residential property owner and declare you no longer qualify to receive a residential exemption • Enter “X”

authorized under UC §59-2-103 for your primary residence, enter “X” and enter the county code where the

residence is located (see instructions or incometax.utah.gov for county codes and additional information). • Enter code

Mail

Utah State Tax Commission

Mail Utah State Tax Commission

RETURNS WITH 210 N 1950 W

ALL OTHER 210 N 1950 W

PAYMENTS to: Salt Lake City, UT 84134-0266

RETURNS to: Salt Lake City, UT 84134-0260

Submit page ONLY if data entered.

Attach completed schedule to your Utah Income Tax return. USTC ORIGINAL FORM 40103 Ź Ź Utah Individual Income Tax Return (continued) TC-40 Pg. 3 SSN Last name 2021 / / / / / .00 .00 .00 .00 .00 .00 .00 .00

Part 1 - Additions to Income (enter the code and amount of each addition to income) Code Amount See instructions or incometax.utah.gov for codes.

•

•

•

•

•

Total additions to income (add all additions to income and enter total here and on TC-40, line 5) Part 2 - Subtractions from Income (enter the code and amount of each subtraction from income)

Code Amount See instructions or incometax.utah.gov for codes.

•

If using subtraction 77 (Native American Income), enter your enrollment •

number and tribal code: Tribe

Enrollment Number Code

•

You •

Spouse • •

•

Total subtractions from income (add all subtractions from income and enter total here and on TC-40, line 8) Part 3 - Apportionable Nonrefundable Credits (enter the code and amount of each credit)

Code Amount See instructions or incometax.utah.gov for codes.

•

•

If you are using credit 18 (Retirement Credit), enter your birth date(s):

You •

Spouse • •

mm/dd/yy mm/dd/yy

•

•

Total apportionable nonrefundable credits (add all Part 3 credits and enter total here and on TC-40, line 24) Part 4 - Nonapportionable Nonrefundable Credits (enter the code and amount of each credit)

Code Amount See instructions or incometax.utah.gov for codes.

•

•

If you are using credit 02 (Qualified Sheltered Workshop), •

enter the sheltered workshop’s name:

•

•

Total nonapportionable nonrefundable credits (add all Part 4 credits and enter total here and on TC-40, line 26) Submit page ONLY if data entered. Attach completed schedule to your Utah Income Tax Return. USTC ORIGINAL FORM 40104 Income Tax Supplemental Schedule TC-40A Pg. 1 SSN Last name 2021 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 / / / /

Part 5 - Refundable Credits (enter the code and amount of each refundable credit)

Code Amount See instructions or incometax.utah.gov for codes.

•

•

•

•

• Total refundable credits (add all refundable credits and enter total here and on TC-40, line 38) Submit page ONLY if data entered. Attach completed schedule to your Utah Income Tax Return. USTC ORIGINAL FORM 40105 Income Tax Supplemental Schedule TC-40A Pg. 2 SSN Last name 2021 .00 .00 .00 .00 .00 .00

Residency Status: • Nonresident: Home state abbreviation: • Part-year resident from: to

mm/dd/yy mm/dd/yy Income

Col. A - UTAH Col. B - TOTAL 1 Wages, salaries, tips, etc. (1040 line 1) 2 Taxable interest income (1040 line 2b) 3 Ordinary dividends (1040 line 3b) 4 IRAs, pensions and annuities - taxable amount (1040 lines 4b and 5b) 5 Social Security benefits - taxable amount (1040 line 6b) 6 Taxable refunds/credits/offsets of state/local income taxes (1040, Schedule 1, line 1) 7 Alimony received (1040, Schedule 1, line 2a) 8 Business income or (loss) (1040, Schedule 1, line 3) 9 Capital gain or (loss) (1040, line 7) 10 Other gains or (losses) (1040, Schedule 1, line 4) 11 Rental real estate, royalties, partnerships, S corps, trusts, etc. (1040, Schd 1, line 5) 12 Farm income or (loss) (1040, Schedule 1, line 6) 13 Unemployment compensation (1040, Schedule 1, line 7) 14 Other income (1040, Schedule 1, line 9) 15 Additions to income from TC-40A, Part 1 (Utah portion only in Utah column) 16 Reserved 17 Reserved 18 Total income (loss) - add lines 1 through 17 for both columns A and B Adjustments Col. A - UTAH Col. B - TOTAL 19 Educator expenses (1040, Schedule 1, line 11) 20 Certain bus. expenses of reservists, performing artists, etc. (1040, Schd 1, line 12) 21 Health savings account deduction (1040, Schedule 1, line 13) 22 Moving expenses (1040, Schedule 1, line 14) - col. A only expenses moving into Utah 23 Deductible part of self-employment tax (1040, Schedule 1, line 15) 24 Self-employed SEP, SIMPLE and qualified plans (1040, Schedule 1, line 16) 25 Self-employed health insurance deduction (1040, Schedule 1, line 17) 26 Penalty on early withdrawal of savings (1040, Schedule 1, line 18) 27 Alimony paid (1040, Schedule 1, line 19a) 28 IRA deduction (1040, Schedule 1, line 20) 29 Student loan interest deduction (1040, Schedule 1, line 21) 30 Reserved 31 Reserved 32 Taxable refunds/credits/offsets of state and local income taxes (1040, Schd 1, line 1) 33 Subtractions from income from TC-40A, Part 2 (Utah portion only in Utah column) 34 Reserved 35 Reserved 36 (see instructions): 37 Total adjustments - add lines 19 through 36 for both columns A and B 38 Subtract line 37 from line 18 for both columns A and B •

•

Line 38, column B must equal TC-40, line 9 Non or Part-year Resident Utah Tax 39 Divide line 38 column A by line 38 column B (to 4 decimal places, not more than 1.0000 or less than 0.0000) 39 40 Subtract TC-40, line 24 from TC-40, line 23 and enter the result (not less than zero) here 40 41 UTAH TAX - Multiply line 40 by the decimal on line 39. Enter on TC-40, page 2, line 25 • 41 Submit this page ONLY if data entered. Attach completed schedule to your Utah Income Tax Return. USTC ORIGINAL FORM 40106 Non and Part-year Resident Schedule TC-40B SSN Last name 2021

/ / / / .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00

.00

.00

NOTE: Part-year residents rarely qualify for this credit. Nonresidents do not qualify for this credit. See instructions. FIRST STATE 1 Enter federal adjusted gross income taxed by both Utah and state of:

1 2 Federal adjusted gross income from TC-40, line 4 (see instructions) 2 3 Divide line 1 by line 2; round to 4 decimal places. Do not enter a number greater than 1.0000. 3 4 Utah income tax from TC-40, line 22. Part-year residents, see instructions. 4 5 Credit limitation - multiply line 4 by decimal on line 3 5 6 Actual income tax paid to state shown on line 1 6

Part-year residents must prorate tax paid to other state. Credit only applies

to the portion of actual taxes paid to the other state on income shown on line 1. 7 Credit for tax paid another state - lesser of line 5 or line 6 7 SECOND STATE 1 Enter federal adjusted gross income taxed by both Utah and state of:

1 2 Federal adjusted gross income from TC-40, line 4 (see instructions) 2 3 Divide line 1 by line 2; round to 4 decimal places. Do not enter a number greater than 1.0000. 3 4 Utah income tax from TC-40, line 22. Part-year residents, see instructions. 4 5 Credit limitation - multiply line 4 by decimal on line 3 5 6 Actual income tax paid to state shown on line 1 6

Part-year residents must prorate tax paid to other state. Credit only applies

to the portion of actual taxes paid to the other state on income shown on line 1. 7 Credit for tax paid another state - lesser of line 5 or line 6 7 THIRD STATE 1 Enter federal adjusted gross income taxed by both Utah and state of:

1 2 Federal adjusted gross income from TC-40, line 4 (see instructions) 2 3 Divide line 1 by line 2; round to 4 decimal places. Do not enter a number greater than 1.0000. 3 4 Utah income tax from TC-40, line 22. Part-year residents, see instructions. 4 5 Credit limitation - multiply line 4 by decimal on line 3 5 6 Actual income tax paid to state shown on line 1 6

Part-year residents must prorate tax paid to other state. Credit only applies

to the portion of actual taxes paid to the other state on income shown on line 1. 7 Credit for tax paid another state - lesser of line 5 or line 6 7 Use additional forms TC-40S if claiming credits for more than three states. Enter the total of all amounts shown on line 7 above on TC-40A, Part 4, using code 17. Submit page ONLY if data entered. Attach completed schedule to your Utah Income Tax Return. 40108 Credit for Income Tax Paid to Another State TC-40S SSN Last name 2021 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00

Line Explanations IMPORTANT 1 Employer/payer ID number from W-2 box “b” or 1099 Do not send your W-2s or 1099s with your return. Instead enter 2 Utah withholding ID number from W-2 box “15” or 1099 W-2 or 1099 information below, but only if there is Utah withholding

(14 characters, ending in WTH, no hyphens) on the form. 3 Employer/payer name and address from W-2 box “c” or 1099 4 Enter “X” if reporting Utah withholding from form 1099 Use additional forms TC-40W if you have more than four W-2s and/or 5 Employee’s Social Security number from W-2 box “a” or 1099 1099s with Utah withholding tax. 6 Utah wages or income from W-2 box “16” or 1099 7 Utah withholding tax from W-2 box “17” or 1099 Enter mineral production withholding from TC-675R in Part 2 of TC-40W;

enter pass-through entity withholding in Part 3 of TC-40W. First W-2 or 1099 Second W-2 or 1099 1

1 2

(14 characters, no hyphens) 2

(14 characters, no hyphens) 3

3 4

4 5

5 6

6 7

7 Third W-2 or 1099 Fourth W-2 or 1099 1

1 2

(14 characters, no hyphens) 2

(14 characters, no hyphens) 3

3 4

4 5

5 6

6 7

7

Enter total Utah withholding tax from all lines 7 here and on TC-40, page 2, line 33: Submit page ONLY if data entered. Attach completed schedule to your Utah Income Tax Return. Do not attach W-2s or 1099s to your Utah return. USTC ORIGINAL FORM 40109 Part 1 - Utah Withholding Tax Schedule TC-40W Pg. 1 SSN Last name 2021 .00 .00 .00 .00 .00 .00 .00 .00

.00

Part 2 -Utah Mineral Production Withholding Tax - TC-675R Do not send TC-675R or Utah Schedules K-1 with return. Enter TC-675R or Schedule K-1 information below. Use additional TC-40Ws if needed. Line Explanations 1 Producer’s EIN from box “2” of TC-675R 4 Pass-through entity EIN if credit from partnership or S corporation 2 Producer’s name from box “1” of TC-675R

(enter EIN from Utah Schedule K-1) 3 Producer’s Utah withholding number from box “3” of TC-675R 5 Utah mineral production withholding tax from box”6” of TC-675R or

(14 characters, ending in WMP, no hyphens)

from Utah Schedule K-1. First TC-675R or Utah Schedule K-1

Second TC-675R or Utah Schedule K-1 1

1 2

2 3

(14 characters, no hyphens) 3

(14 characters, no hyphens) 4

4 5

5 Third TC-675R or Utah Schedule K-1

Fourth TC-675R or Utah Schedule K-1 1

1 2

2 3

(14 characters, no hyphens) 3

(14 characters, no hyphens) 4

4 5

5

Enter total mineral production withholding tax from all lines 5 here and on TC-40, page 2, line 36. Part 3 -Utah Pass-through Entity Taxpayer Withholding - Utah Schedule K-1 Do not send Utah Schedule(s) K-1 with return. Enter information below. Use additional TC-40Ws if needed. Line Explanations 1 Pass-through entity EIN from Utah Schedule K-1 box “A” 2 Name of pass-through entity from Utah Schedule K-1 box “B” 3 Utah withholding tax paid by pass-through entity First Utah Schedule K-1 Second Utah Schedule K-1 1

1 2

2 3

3 Third Utah Schedule K-1 Fourth Utah Schedule K-1 1

1 2

2 3

3

Enter total pass-through withholding tax from all lines 3 here and on TC-40, page 2, line 35: Submit page ONLY if data entered. Attach completed schedule to your Utah Income Tax Return. USTC ORIGINAL FORM 40110 Mineral Production and Pass-through Withholding TC-40W Pg. 2 SSN Last name 2021 .00 .00 .00 .00

.00 .00 .00 .00 .00

.00