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2020 State Filing Instructions

Taxpayer Name: Mark Thomas Taxpayer SSN: 016-68-5019

Username: markjt3 Password:
Customer email: [email protected]
Mailing Address: 158 I Street City/State/Zip: Boston, MA 02127

INSTRUCTIONS
INCLUDED IN THIS PACKAGE IS YOUR COMPLETED MASSACHUSETTS TAX RETURN AND ALL SUPPORTING FORMS
AND SCHEDULES REQUIRED FOR FILING.

PAYMENT INSTRUCTIONS
TOTAL TAX: $646

PAYMENTS: $180

BALANCE AMOUNT: $466

FOLLOW THE INSTRUCTIONS PROVIDED ON FORM PV.

 2020 Form 1
MA20001011181
Massachusetts Resident Income Tax Return
FOR FULL YEAR RESIDENTS ONLY
For the year January 1–December 31, 2020 or other taxable

Year beginning Ending

MARK J THOMAS 016685019

158 I STREET BOSTON MA 02127

Fill in if: X Original return Amended return Amended return due to federal change Apt. no.
State Election Campaign Fund: $1 You $1 Spouse TOTAL 0
Fill in if veteran of U.S. armed forces who served in Operations Enduring Freedom, Iraqi Freedom, Noble Eagle
or Sinai Peninsula You Spouse
Taxpayer deceased You Spouse
Fill in if under age 18 You Spouse
a. Total federal income 10146 Name changed since 2019
b. Federal adjusted gross income 10146 Fill in if noncustodial parent
1. Filing status (select one only): X Single Fill in if filing Schedule TDS
Married filing jointly
Married filing separate return
Head of household You are a custodial parent who has released claim to exemption for child(ren)
2. Exemptions
a. Personal exemptions 2a 4400
b. Number of dependents. (Do not include yourself or your spouse.) Enter number × $1,000 = 2b
c. Age 65 or over before 2021 You + Spouse = 0 × $700 = 2c
d. Blindness You + Spouse = 0 × $2,200 = 2d
e. Medical/dental 2e
f. Adoption 2f
g. Total exemptions. Add items 2a through 2f. Enter here and on line 18 2g 4400
SIGN HERE. Under penalties of perjury, I declare that to the best of my knowledge and belief this return and enclosures are true, correct and complete.
Your signature Date Spouse’s signature Date

[email protected] 6173775622
PRIVACY ACT NOTICE AVAILABLE UPON REQUEST
 2020 Form 1, pg. 2
MA20001021181
Massachusetts Resident Income Tax Return
016685019

3. Wages, salaries, tips 3

4. Taxable pensions and annuities 4
5. Mass. bank interest: a. – b. exemption =5
6a. Business/profession income/loss 6a
6b. Farming income/loss 6b
7. Rental, royalty and REMIC, partnership, S corp., trust income/loss 7
8a. Unemployment 8a 20346
8b. Mass. lottery winnings 8b
9. Other income from Schedule X, line 5 9
10. TOTAL 5.0% INCOME 10 20346
11a. Amount paid to Soc. Sec. Medicare, R.R., U.S. or Mass. Retirement 11a
11b. Amount your spouse paid to Soc. Sec., Medicare, R.R., U.S. or Mass. Retirement 11b
12. Child under age 13, or disabled dependent/spouse care expenses 12
13. Number of dependent member(s) of household under age 12, or dependents age 65 or over (not you or your spouse) as of
12/31/20, or disabled dependent(s)
Not more than two. a. × $3,600 = 13
14. Rental deduction. a. 6000 ÷ 2 = 14 3000
15. Other deductions from Schedule Y, line 19 15
16. Total deductions. Add lines 11 through 15 16 3000
17. 5.0% INCOME AFTER DEDUCTIONS. Subtract line 16 from line 10. Not less than “0” 17 17346
18. Exemption amount 18 4400
19. 5.0% INCOME AFTER EXEMPTIONS. Subtract line 18 from line 17. Not less than “0” 19 12946
20. INTEREST AND DIVIDEND INCOME 20
21. TOTAL TAXABLE 5.0% INCOME. Add lines 19 and 20 21 12946
BE SURE TO INCLUDE THIS PAGE WITH FORM 1, PAGE 1
 2020 Form 1, pg. 3
MA20001031181
Massachusetts Resident Income Tax Return
016685019

22. TAX ON 5.0% INCOME. Note: If choosing the optional 5.85% tax rate, fill in and multiply line 21 and the
amount in Schedule D, line 21 by .0585 22 646
23. 12% INCOME. Not less than “0.” a. × .12 = 23
24. TAX ON LONG-TERM CAPITAL GAINS. Not less than “0.” Fill in if filing Schedule D-IS 24
Fill in if any excess exemptions were used in calculating lines 20, 23 or 24
25. Credit recapture amount (from Credit Recapture Schedule) 25
26. Additional tax on installment sale 26
27. If you qualify for No Tax Status, fill in and enter “0” on line 28
28. TOTAL INCOME TAX. Add lines 22 through 26 28 646
29. Limited Income Credit 29
30. Income tax due to another state or jurisdiction 30
31. Other credits from Credit Manager Schedule 31
32. INCOME TAX AFTER CREDITS. Subtract the total of lines 29 through 31 from line 28. Not less than “0” 32 646
33. Voluntary Contributions
a. Endangered Wildlife Conservation 33a
b. Organ Transplant Fund 33b
c. Massachusetts Public Health HIV and Hepatitis Fund 33c
d. Massachusetts U.S. Olympic Fund 33d
e. Massachusetts Military Family Relief Fund 33e
f. Homeless Animal Prevention and Care 33f
Total. Add lines 33a through 33f 33
34. Use tax due on Internet, mail order and other out-of-state purchases 34
35. Health care penalty a. You + b. Spouse 35
36. Amended return only. Overpayment from original return 36
37. INCOME TAX AFTER CREDITS PLUS CONTRIBUTIONS AND USE TAX. Add lines 32 through 36 37 646
 2020 Form 1, pg. 4
MA20001041181
Massachusetts Resident Income Tax Return
016685019

38. Massachusetts income tax withheld 38

39. 2019 overpayment applied to your 2020 estimated tax 39 180
40. 2020 Massachusetts estimated tax payments 40
41. Payments made with extension 41
42. Amended return only. Payments made with original return. Not less than “0” 42
43. Earned Income Credit. a. Number of qualifying children b. Amount from U.S. return × .30 = 43
Note: You cannot claim the Earned Income Credit if your filing status is married filing separately unless you qualify
for an exception (see instructions). Fill in if you qualify for this exception
44. Senior Circuit Breaker Credit 44
45. Other Refundable Credits 45
46. Excess Paid Family Leave Withholding 46
47. TOTAL. Add lines 38 through 46 47 180
48. Overpayment. Subtract line 37 from line 47 48
49. Amount of overpayment you want applied to your 2021 estimated tax 49
50. Refund. Subtract line 49 from line 48. Mail to: Massachusetts DOR, PO Box 7000, Boston, MA 02204 50

Direct deposit of refund. Type of account checking

savings
RTN # account #

51. Tax due. Pay online at www.mass.gov/dor/payonline. Mail to: Mass. DOR, PO Box 7003, Boston, MA 02204 51 466
Interest Penalty M-2210 amt. EX enclose
Form M-2210

May the Department of Revenue discuss this return with the preparer shown here?
I do not want preparer to file my return electronically (this may delay your refund) Paid preparer’s
Print paid preparer’s name Date Check if self-employed SSN/PTIN

Paid preparer’s signature Paid preparer’s phone Paid preparer’s EIN

BE SURE TO INCLUDE THIS PAGE WITH FORM 1, PAGE 1

 2020 Schedule HC
MA20029011181

Schedule HC, Health Care Information, must be completed by all

full-year residents and certain part-year residents (see instructions).
Note: Schedule HC must be enclosed with your Form 1 or Form
1-NR/PY. Failure to do so will delay the processing of your return.
MARK J THOMAS 016685019

1a. Date of birth 02011983 1b. Spouse’s date of birth 1c. Family size 1

2. Federal adjusted gross income 2 10146

3. Indicate the time period that you were enrolled in a Minimum Creditable Coverage (MCC) health insurance plan(s). The Form MA 1099-HC from your
insurer will indicate whether your insurance met MCC requirements. Note: MassHealth, Medicare, and health coverage for U.S. Military, including
Veterans Administration and Tri-Care, meet the MCC requirements. If you did not receive a Form MA 1099-HC from your insurer, or you had insurance
that did not meet MCC requirements, see the special section on MCC requirements in the instructions.

See instructions if, during 2020, you turned 18, you 3a You: X Full-year MCC Part-year MCC No MCC/None
were a part-year resident or a taxpayer was deceased. 3a Spouse: Full-year MCC Part-year MCC No MCC/None
If you filled in the full-year or part-year MCC oval, go to line 4. If you filled in No MCC/None, go to line 6.

4. Indicate the health insurance plan(s) that met the Minimum Creditable Coverage (MCC) requirements in which you were enrolled in 2020, as
shown on Form MA 1099-HC (check all that apply). If you did not receive this form, fill in line(s) 4f and/or 4g and see instructions. Fill in if you were
enrolled in private insurance and MassHealth or Commonwealth Care and enter your private insurance information in line(s) 4f and/or 4g and go
to line 5.
4a. Private insurance, including ConnectorCare (completes line(s) 4f and/or 4g below) You Spouse
4b. MassHealth. Fill in and go to line 5 X You Spouse
4c. Medicare (including a replacement or supplemental plan). Fill in and go to line 5 You Spouse
4d. U.S. Military (including Veterans Administration and Tri-Care). Fill in and go to line 5 You Spouse
4e. Other program (enter the program name(s) only in lines 4f and/or 4g below). Note: Health Safety Net You Spouse
is not considered insurance or minimum creditable coverage.

4f. Your Health Insurance. Complete if you answered line(s) 4a or 4e and go to line 5. Fill in if you were not issued Form MA 1099-HC.

4g. Spouse Health Insurance. Complete if you answered line(s) 4a or 4e and go to line 5. Fill in if you were not issued Form MA 1099-HC.

5. If you had health insurance that met MCC requirements for the full-year, including private insurance, MassHealth, Commonwealth Care or ConnectorCare,
you are not subject to a penalty. Skip the remainder of this schedule and continue completing your tax return. Other wise, go to line 6.

If you had Medicare (including a replacement or supplemental plan), U.S. Military (including Veterans Administration and Tri-Care), or other government
insurance at any point during 2020, you are not subject to a penalty. Skip the remainder of this schedule and continue completing your tax return.
Otherwise, go to line 6.
 2020 Schedule HC, pg. 2
MA20029021181

Your Health Insurance

6. Was your income in 2020 at or below 150% of the federal poverty level? 6 Yes No
If you answer Yes, you are not subject to a penalty in 2020. Skip the remainder of this schedule and complete your tax return. If you answer No and you were enrolled
in a health insurance plan that met the MCC requirements for part, but not all, of 2020, go to line 7. If you answer No and you had no insurance or you were enrolled
in a plan that did not meet the MCC requirements during the period that the mandate applied, go to line 8a.
7. Complete this section only if you, and/or your spouse if married filing jointly, were enrolled in a health insurance plan(s) that met the Minimum Creditable
Coverage (MCC) requirements for part, but not all of 2020. Fill in below the months that met the MCC requirements, as shown on Form MA 1099-HC. If you
did not receive this form, fill in the months you were covered by a plan that met the MCC requirements at least 15 days or more. If, during 2020, you turned
18, you were a part-year resident or a taxpayer was deceased, fill in the oval(s) below for the month(s) that met the MCC requirements during the period
that the mandate applied. See instructions.
You may only fill in the month(s) you had health insurance that met MCC requirements. If you had health insurance, but it did not meet MCC requirements,
you must skip this section and go to line 8a.

Months Covered By Health Insurance

You: Jan. Feb. March April May June July Aug. Sept. Oct. Nov. Dec.
Spouse: Jan. Feb. March April May June July Aug. Sept. Oct. Nov. Dec.
If you had four or more consecutive months either with no insurance or insurance that did not meet the MCC requirements (four or more blank months in a row),
go to line 8a. Otherwise, a penalty does not apply to you in 2020. Skip the remainder of this schedule and complete your tax return.

Religious Exemption and Certificate of Exemption

8a. Religious exemption: Are you claiming an exemption from the requirement to purchase health insurance based 8a You Yes No
on your sincerely held religious beliefs that cause you to object to substantially all forms of treatment covered by
health insurance? Spouse Yes No
If you answer Yes, go to line 8b. If you answer No, go to line 9.
8b. If you are claiming a religious exemption in line 8a, did you receive medical health care during the 2020 tax year? 8b You Yes No
Spouse Yes No
If you answer No to line 8b, skip the remainder of this schedule and continue completing your tax return. If you answer Yes to line 8b, go to line 9.
9. Certificate of exemption: Have you obtained a Certificate of Exemption issued by the Massachusetts Health 9 You Yes No
Connector for the 2020 tax year? Spouse Yes No
If you answer Yes, enter the certificate number, skip the remainder of this schedule and continue completing your tax
return. If you answer No to line 9, go to line 10.
 2020 Schedule HC, pg. 3
MA20029031181

Affordability as Determined By State Guidelines

Note: This section will require the use of worksheets and tables found in the instructions. You must complete the worksheet(s) to determine if health insurance was
affordable to you during the 2020 tax year.
10. Did your employer offer affordable health insurance that met minimum creditable coverage requirements 10 You Yes No
as determined by completing the Schedule HC Worksheet for Line 10 in the instructions? Spouse Yes No
Fill in No if your employer did not offer health insurance that met minimum creditable coverage requirements, you were not eligible for health insurance offered by
your employer, you were self-employed or you were unemployed.
11. Were you eligible for government-subsidized health insurance as determined by completing the Schedule HC 11 You Yes No
Worksheet for Line 11 in the instructions? Spouse Yes No
If you answer No, go to line 12. If you answer Yes, go to the Health Care Penalty Worksheet in the instructions to calculate your penalty amount.
12. Were you able to purchase affordable private health insurance that met minimum creditable coverage requirements 12 You Yes No
as determined by completing the Schedule HC Worksheet for Line 12 in the instructions? Spouse Yes No
If you answer No, you are not subject to a penalty. Continue completing your tax return. If you answer Yes, go to the Health Care Penalty Worksheet in the
instructions to calculate your penalty amount.

Complete Only If You Are Filing An Appeal

You must complete the Health Care Penalty Worksheet to determine your penalty amount before completing this section.
You may have grounds to appeal if you were unable to obtain affordable insurance that meets the minimum creditable coverage requirements in 2020 due to a
hardship or other circumstances. The grounds for appeal are explained in more detail in the instructions. If you believe you have grounds for appealing the penalty,
fill in the field(s) below. The appeal will be heard by the Massachusetts Health Connector. By filling in the field below, you (or your spouse if married filing jointly) are
authorizing DOR to share information from your tax return, including this schedule, with the Massachusetts Health Connector for purposes of deciding your appeal.
You will receive a follow-up letter asking you to state your grounds for appeal in writing, and submit supporting documentation. Failure to respond to
that letter within the time specified in the letter will lead to dismissal of your appeal and will result in a future assessment of a penalty. Once your
documentation is received, it will be reviewed by the Massachusetts Health Connector and you may be required to attend a hearing on your case. You will be required
to file your claims under the pains and penalties of perjury.
Note: If you are filing an appeal, make sure you have calculated the penalty amount that you are appealing, but do not assess yourself or enter a penalty amount
on your Form 1 or Form 1-NR/PY. Also, do not include any hardship documentation with your original return. You will be required to submit substantiating hardship
documentation at a later date during the appeal process.

You: I wish to appeal the penalty. I authorize DOR to share this tax return including this schedule with the Massachusetts Health Connector
for purposes of deciding this appeal.

Spouse: I wish to appeal the penalty. I authorize DOR to share this tax return including this schedule with the Massachusetts Health Connector
for purposes of deciding this appeal.
 2020 Schedule B
MA20010011181

MARK J THOMAS 016685019

Part 1. Interest and Dividend Income

1. Total interest income 1
2. Total ordinary dividends 2
3. Other interest and dividends not included above 3
4. Total interest and dividends 4
5. Total interest from Massachusetts banks 5
6a. Other interest and dividends to be excluded 6a
6b. Part-year/Nonresidents only 6b
7. Subtotal 7
8. Allowable deductions from your trade or business 8
9. Subtotal 9

Part 2. Short-Term Capital Gains/Losses and Long-Term Gains on Collectibles

10. Massachusetts short-term capital gains 10
11. Massachusetts long-term capital gains on collectibles and pre-1996 installment sales 11
12. Massachusetts gain on the sale, exchange or involuntary conversion of property used in a trade or business and
held for one year or less 12
13a. Add lines 10 through 12 13a
13b. Part-year/Nonresidents only 13b
13c. Subtract line 13b from line 13a. Not less than 0 13c
14. Allowable deductions from your trade or business 14
15. Subtotal 15
16. Massachusetts short-term capital losses 16
17. Massachusetts loss on the sale, exchange or involuntary conversion of property used in a trade or business and
held for one year or less 17
18. Prior short-term unused losses for years beginning after 1981 18 -180
 2020 Schedule B, pg. 2
016685019 MA20010021181

19a. Combine lines 15 through 18 19a -180

19b. Part-year/Nonresidents only 19b
19c. Exclude line 19b losses from line 19a 19c -180
20. Short-term losses applied against interest and dividends 20
21. Available short-term losses 21 -180
22. Short-term losses applied against long-term gains 22
23. Short-term losses available for carryover in 2021 23 -180
24. Short-term gains and long-term gains on collectibles 24
25. Long-term losses applied against short-term gain 25
26. Subtotal 26
27. Long-term gains deduction 27
28. Short-term gains after long-term gains deduction 28

Part 3. Adjusted Gross Interest, Dividends, Short-Term Capital Gains and Long-Term Gains on Collectibles
29. Enter the amount from line 9 29
30. Short-term losses applied against interest and dividends 30
31. Subtotal interest and dividends 31
32. Long-term losses applied against interest and dividends 32
33. Adjusted interest and dividends 33
34. Enter the amount from line 28 34
35. Adjusted gross interest, dividends and certain capital gains 35
36. Excess exemptions 36
37. Subtract line 36 from line 35 37
38. Interest and dividends taxable at 5.0% 38
39. Taxable 12% capital gains 39
40. Available short-term losses for carryover in 2021 40 -180
 5 DETACH HERE 5
----------------------------------------------------------------------------------------------------------------
2020 )RUP 39
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Payment for period end date (mm/dd/yyyy) Tax type Voucher type ID type Vendor code
12/31/2020 053 01 005 1
Name of taxpayer Social Security number $PRXQW (QFORVHG
MARK J THOMAS 016685019  466.00
Name of taxpayer’s spouse Social Security number of taxpayer’s spouse

Street address &LW\7RZQ 6WDWH =LS

158 I STREET BOSTON MA 02127
3KRQH (PDLO )LOO LQ LI QDPHDGGUHVV FKDQJHG VLQFH 2019
(617) 377 - 5622 [email protected]
Pay online at mass.gov/masstaxconnect. Or, return this voucher with check or money order payable to: Commonwealth of Massachusetts.
Mail to: Massachusetts Department of Revenue, PO Box 7062, Boston, MA 02204.

00100016685019 123120 0000000000 053 010051181 00000466009