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GARDENIA CITIZEN B110991 FORM NOTE: PLEASE COMPLETE ALL INFORMATION
NAME (Last, First, M.I.) GARDENIA SECURITY CODE DATE OF BIRTH
Grofyid Pudgy R. A012495304167 11/6/1996
PRESENT ADDRESS (INCLUDE APT. NO. OR RURAL ROUTE) Apt # City, Town or Post Office State Zip Code
8 Fraggle Road Gardenia Gardenia A4554
TELEPHONE
Home: (X)4564-4546 Work: N/A		 WOLMAIL ADDRESS
Pudgy@Gardenia.nork        		 WHAT IS YOUR PRIMARY LANGUAGE?
(Optional)

English

 EMPLOYER
Self Employed		 DATE EMPLOYED
N/A
EMPLOYEE IDENTIFICATION NUMBER (If applicable)
N/A		 Personal Physician: Woolma Yuna Physician's Telephone: (X)4444-8789 COUNTY OF RESIDENCE
Wendigo		 SCHOOL DISTRICT NO. (SEE PAGE 14)
RERT-86V4
SPOUSE'S NAME (Last, First, M.I.) GARDENIA SECURITY CODE
N/A N/A N/A N/A
If physician named above is not available in the event of an emergency, notify
Name: Blackie Zu Relationship: Father Telephone: (X)4654-4876
Name: Robin Bobbin Relationship: Mother Telephone: (X)4654-4876
AGE 65 OR OVER
YOURSELFSPOUSE		 BLIND
YOURSELFSPOUSE		 100% DISABLED
YOURSELFSPOUSE		 NON-OBLIGATED SPOUSE
YOURSELFSPOUSE
INCOME 1. What did you report as your total income on your last Gardenia return?
2. Subtract any state income tax refund included in your current Gardenia income.
3. TOTAL GARDENIA INCOME. Subtract Line 2 from Line 1.		 1.
2.
3.		 48.78 Pogs
-4.53 Pogs
=44.25 Pogs
DEDUCTIONS Mark one filing status box and enter exemption amount here. .................. 4. 32.25 Pogs
A. Single - 12 Pogs(See Box G before checking) D. Married filing separate (spouse NOT
filing)-24 Pogs
B. Married filing joint federal and combined Gardenia-24 Pogs
(Only one spouse with income)
Check which spouse had income: YourselfSpouse		 E. Head of household -20 Pogs
F. Qualifying widow(er) with dependent
child-20 Pogs
C. Married and filing separate-12 Pogs G. Claimed as a dependent on another person's Gardenia tax return-0.00 Pogs
DEDUCTIONS 5. What was your Gardenia income tax reported on your recent return? 59.77 p Enter this amount or $50 ($100 if married filing combined, whichever is less. 5. +50.00 Pogs
6. What is your standard or itemized deduction (see Gardenia Citizen's Manual for amounts)? ........ ................. 6. +9.88 Pogs
7. Enter the total number of dependents you claimed on your Gardenia return and multiply by $12. (Do not include yourself or spouse) x 12 Pogs 7. +.00 Pogs
8. Enter the total number of dependents age 65 or over claimed on your Gardenia return and multiply by 10 Pogs. Go to FAQ J. x 10 Pogs 8. +.00 Pogs
9. TOTAL DEDUCTIONS. Add Lines 4 through 8. ........... .......... 9. =92.13 Pogs
Taxes 10. TOTAL GARDENIA INCOME(Line 3) minus TOTAL DEDUCTIONS (Line 9) This is your Gardenia taxable income. .......... 10. -47.88 Pogs
11. TOTAL TAXES Use the Gardenia Citizen's Manual to figure the tax. .......... 11. 4.83 Pogs
Payments/Refunds 12. What is the Gardenia withholding for you or your spouse? Enter the total amount from all R3(s) and 9C-R(s). .......... 12. 7.29 Pogs
13. Did you make any Gardenia estimated tax payments for last filing season? If so, include any amount of your recent refund credited to your recent estimated payments. (This may not apply to you.) .......... 13. .00 Pogs
14. TOTAL PAYMENTS. Add Lines 12 and 13 and enter amount here. .......... 14. 7.29 Pogs
15. If amount of TOTAL PAYMENTS (Line 14) is larger than amount of TOTAL TAXES (Line 11), enter the difference here. You have overpaid. If not, enter the amount on Line 19. .......... 15. 2.46 Pogs
16. You may donate part of your refund or contribute additional payments to any or all of the trust funds listed to the right. Please indicate your choices and the amount of your donation for each fund in the appropriate boxes. 16. Furry Trust Fund Hatchling Trust Fund Graymuzzle Home Delivered Meals Trust Fund Veterans Trust Fund Softness Trust Fund
.00 Pogs .00 Pogs .00 Pogs .00 Pogs 4.19 Pogs
17. What is the amount from Line 15 you want applied to next year's taxes? .......... 17. 1.76 Pogs
18. Your REFUND. Line 15 minus Lines 16 and 17. Mail to: Department of Revenue, P.O. Box 10, Gardenia, Gardenia, 00001 18..00 Pogs OR If payments are smaller than tax, you have an AMOUNT DUE. Mail to: Department of Revenue, P.O. Box 10, Gardenia, Gardenia, 00001 19. 3.49 Pogs
Signature Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief it is true, correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which he/she has any knowledge. As provided in chapter 45, GM, a penalty of up to 500 Pogs shall be imposed on any individual who files a frivolous return. DOR ONLY X
 R
 Q
M
I authorize the Director of Revenue or delegate to discuss my return and enclosures with the preparer or any member of his/her firm. YESNO PREPARER'S PHONE NUMBER
(X)4554-4564
YOUR SIGNATURE DATE PREPARER'S SNIGATURE* FEIN OR GSC
Sig 4/2/2005 Sig 5437205QP
SPOUSE'S SIGNATURE DAYTIME TELEPHONE PREPARER'S ADDRESS AND ZIP CODE DATE
N/A N/A 3 Bard Blazon, A4554 2/3/2005
*Co-Signed by Snig
Check all items that apply, past or present, to your health history. Explain any `yes' answers.
Personal health/accident insurance carrier: NOOZLE Group EIO
LIST ALLERGIES: (Plants, food, medicines, insects, Other): Siberian Cheese
MEDICINES: TO BE TAKEN AND DOSAGE: N/A
GENERAL INFORMATION Yes No Yes No Yes No
Attention Defecit Diabetes Asthma
Cancer/Leukemia Heart Trouble Kidney Disease
Convulsions Hemophilia High blood pressure
Explain any `yes' answers:
1. List any physical or behavioral conditions that may affect or limit full participation in swimming, backpacking, hiking long distances, or playing strenuously physical games:
2. List any equipment needed (wheelchair, braces, glasses, contacts, etc.):
Tetanus toxoid Sig Measles Sig Polio: Sig Check Box: N Abn
Diptheria Sig Mumps Sig Growth Development
Pertussis Sig Rubella Sig Cardiopulmonary sys.
Height: 5'4" Weight: 151 BP: 114/74 Pulse: 92 Musculoskeletal
Lab: Urinalysis (dipstick) Albumin: 20 Sugar: 0.005
VISION: Normal: 20/20 Glasses: N/A Contacts: N/A
HEARING: Normal: X R+L Clinically Abnormal: No Explain:
Explain:
LIMITATIONS
Activity Restrictions:
Diet Restrictions: No chocolate
Signature...............SigM.D./D.O. Licence No. ....E022053101619
Signature...............P.A./R.N.P.(see note below)
Date: 4/3/2005 Address: 8 N. Caboose
Phone: (X)6564-4564 City/State/ZIP: Gardenia, Gardenia, A4554

NOTE: If this exam is performed by a Physician's Assistant or a Registered Nurse Practioner, under the Collaborative Practice Act, the name of such Co-Practicing Physician must also appear on this form.

TREATMENT AUTHORIZATION

The information provided on this form is correct to the best of my knowledge. In the event of an emergency, if fursons listed on the reverse side of this form as emergency contacts cannot be reached, I hearby give permission to the physician selected by the adult leader in charge to secure proper treatment, which may inculde anesthesia, surgery, or injections, of medication.
Date: 2/3/2005 Signature of parent/guardian or adult participant: Sig