IT-201

Department of Taxation and Finance

Resident Income Tax Return

New York State • New York City • Yonkers • MCTMT
)RU WKH IXOO \HDU -DQXDU\   WKURXJK 'HFHPEHU   RU ¿VFDO \HDU EHJLQQLQJ ... 23

PY
and ending ...
For help completing your return, see the instructions, Form IT-201-I.
Your ¿UVWQDPH 0, <RXUODVWQDPH(for a joint return, enter spouse’s name on line below) <RXUGDWHRIELUWK(mmddyyyy) <RXU6RFLDO6HFXULW\QXPEHU

MICHELLE R COTE RUIZ 10291999 121889036

NO HANDWRITTEN ENTRIES, OTHER THAN SIGNATURE, ON THIS FORM

Spouse’s¿UVWQDPH 0, 6SRXVH¶VODVWQDPH 6SRXVH¶VGDWHRIELUWK(mmddyyyy) 6SRXVH¶V6RFLDO6HFXULW\QXPEHU

CO
0DLOLQJDGGUHVV(see instructions) (number and street or PO Box) $SDUWPHQWQXPEHU 1HZ<RUN6WDWHFRXQW\RIUHVLGHQFH

526E 138TH ST 16 BRONX

&LW\YLOODJHRUSRVWRႈFH 6WDWH =,3FRGH &RXQWU\ 6FKRROGLVWULFWQDPH
BRONX NY 10454 BRONX
Taxpayer’s permanent home address (see instructions) (number and street or rural route) $SDUWPHQWQXPEHU
6FKRROGLVWULFW
FRGHQXPEHU ............... 068
&LW\YLOODJHRUSRVWRႈFH 6WDWH =,3FRGH 7D[SD\HU¶VGDWHRIGHDWK (mmddyyyy) 6SRXVH¶VGDWHRIGHDWK (mmddyyyy)
Decedent
EW NY information

D1 'LG\RXKDYHD¿QDQFLDODFFRXQWORFDWHG
A Filing c X Single LQDIRUHLJQFRXQWU\" ........................................... <HV 1R X
status
D2 (1) 'LG\RXRU\RXUVSRXVHmaintain living
0DUULHG¿OLQJMRLQWUHWXUQ
(mark an d (enter spouse’s Social Security number above) quarters in YonkersIRUDQ\SDUWRI" ... <HV 1R X

LE
X in one
,IYes:
box): 0DUULHG¿OLQJVHSDUDWHUHWXUQ
e (enter spouse’s Social Security number above)  1XPEHURIPRQWKVyouOLYHGLQ<RQNHUVLQ...........
I
f +HDGRIKRXVHKROG(with qualifying person)  1XPEHURIPRQWKVyour spouseOLYHGLQ<RQNHUVLQ
EV

,INo:
g 4XDOLI\LQJVXUYLYLQJVSRXVH

FI
(4) 'LG\RXRU\RXUVSRXVHZRUNLQ<RQNHUVZKLOH
QRWOLYLQJLQ<RQNHUVIRUDQ\SDUWRI....... <HV 1R X
B Did you itemize\RXUGHGXFWLRQVRQ
X
\RXUIHGHUDOLQFRPHWD[UHWXUQ"............ <HV 1R
E (1) 'LG\RXRU\RXUVSRXVHmaintain living quarters in
C Can you be claimedDVDGHSHQGHQW NYC WKLVLQFOXGHVWKH%URQ[%URRNO\Q0DQKDWWDQ
RQDQRWKHUWD[SD\HU¶VIHGHUDOUHWXUQ" ........... <HV 1R
X 4XHHQVDQG6WDWHQ,VODQG GXULQJ".......... <HV 1R
PR

T
 (QWHUWKHQXPEHURIGD\VVSHQWLQ1<&LQ
(any part of a day spent in NYC is considered a day) .........

F NYC residents and NYC part-year residents only:

12
NO

 1XPEHURIPRQWKVyouOLYHGLQ1<&LQ ................

 1XPEHURIPRQWKVyour spouse OLYHGLQ1<&LQ.....

G (QWHU\RXU2-character special condition

H Dependent information code(s) if applicable ...........................................

)LUVWQDPH 0, /DVWQDPH 5HODWLRQVKLS 6RFLDO6HFXULW\QXPEHU 'DWHRIELUWK(mmddyyyy)

DO

,IPRUHWKDQGHSHQGHQWVPDUNDQXLQWKHER[
201001231201
)RUR௻FHXVHRQO\
Page 2 of 4 IT-201  <RXU6RFLDO6HFXULW\QXPEHU
121889036
Federal income and adjustments
Whole dollars only

PY
1 :DJHVVDODULHVWLSVHWF ........................................................................................................... 1 30053.
2 7D[DEOHLQWHUHVWLQFRPH .............................................................................................................. 2 .
3 2UGLQDU\GLYLGHQGV...................................................................................................................... 3 .

NO HANDWRITTEN ENTRIES, OTHER THAN SIGNATURE, ON THIS FORM

4 7D[DEOHUHIXQGVFUHGLWVRURႇVHWVRIVWDWHDQGORFDOLQFRPHWD[HV(also enter on line 25) .......... 4 .
5 $OLPRQ\UHFHLYHG ........................................................................................................................ 5 .

CO
6 %XVLQHVVLQFRPHRUORVV(submit a copy of federal Schedule C, Form 1040) ..................................... 6 .
7 &DSLWDOJDLQRUORVV(if required, submit a copy of federal Schedule D, Form 1040) ............................. 7 .
8 2WKHUJDLQVRUORVVHV(submit a copy of federal Form 4797) ............................................................ 8 .
9 7D[DEOHDPRXQWRI,5$GLVWULEXWLRQV,IUHFHLYHGDVDEHQH¿FLDU\PDUNDQXLQWKHER[ .. 9 .
10 7D[DEOHDPRXQWRISHQVLRQVDQGDQQXLWLHV,IUHFHLYHGDVDEHQH¿FLDU\PDUNDQXLQWKHER[ 10 .
11 5HQWDOUHDOHVWDWHUR\DOWLHVSDUWQHUVKLSV6FRUSRUDWLRQVWUXVWVHWF(submit copy of federal Schedule E, Form 1040) 11 .

12 5HQWDOUHDOHVWDWHLQFOXGHGLQOLQH .............................. 12

EW .
13 )DUPLQFRPHRUORVV(submit a copy of federal Schedule F, Form 1040) ........................................... 13 .
14 8QHPSOR\PHQWFRPSHQVDWLRQ................................................................................................... 14 .
15 7D[DEOHDPRXQWRI6RFLDO6HFXULW\EHQH¿WV(also enter on line 27) .............................................. 15 .
16 Other income Identify: 16 .

LE
17 $GGOLQHV1 through 11 and 13 through 16 ............................................................................. 17 30053.
18 7RWDOIHGHUDODGMXVWPHQWVWRLQFRPH Identify: 18 .
I
19 )HGHUDODGMXVWHGJURVVLQFRPH(subtract line 18 from line 17) ...................................................... 19 30053.
EV

FI
New York additions
20 ,QWHUHVWLQFRPHRQVWDWHDQGORFDOERQGVDQGREOLJDWLRQV EXWQRWWKRVHRI1<6RULWVORFDOJRYHUQPHQWV 20 .
21 3XEOLFHPSOR\HH K UHWLUHPHQWFRQWULEXWLRQVIURP\RXUZDJHDQGWD[VWDWHPHQWV.................. 21 .
22 New York’s FROOHJHVDYLQJVSURJUDPGLVWULEXWLRQV ............................................................. 22 .
PR

23 Other (Form IT-225, line 9) ............................................................................................................ 23 .

T
24 $GGOLQHV19WKURXJK23 ............................................................................................................. 24 30053.
NO

New York subtractions

25 7D[DEOHUHIXQGVFUHGLWVRURႇVHWVRIVWDWHDQGORFDOLQFRPHWD[HV(from line 4) 25 .

26 3HQVLRQVRI1<6DQGORFDOJRYHUQPHQWVDQGWKHIHGHUDOJRYHUQPHQW 26 .
27 7D[DEOHDPRXQWRI6RFLDO6HFXULW\EHQH¿WV(from line 15) ... 27 .
28 ,QWHUHVWLQFRPHRQ86JRYHUQPHQWERQGV ..................... 28 .
29 3HQVLRQDQGDQQXLW\LQFRPHH[FOXVLRQ ............................ 29 .
30 New York’sFROOHJHVDYLQJVSURJUDPGHGXFWLRQHDUQLQJV 30 .
DO

31 Other (Form IT-225, line 18) ................................................. 31 .

32 $GGOLQHVWKURXJK ............................................................................................................. 32 .
33 New York adjusted gross income (subtract line 32 from line 24) ................................................. 33 30053.

Standard deduction or itemized deduction

34 (QWHU\RXUstandard deduction or\RXUitemized deduction (from Form IT-196)

0DUNDQX LQWKHDSSURSULDWHER[ X Standard - or - Itemized 34 8000.
35 6XEWUDFWOLQHIURPOLQH(if line 34 is more than line 33, leave blank) ......................................... 35 22053.
36 'HSHQGHQWH[HPSWLRQV(enter the number of dependents listed in item H) ........................................ 36 000.00

37 Taxable income (subtract line 36 from line 35) .............................................................................. 37 22053.

201002231201
1DPH V DVVKRZQRQSDJH <RXU6RFLDO6HFXULW\QXPEHU IT-201   Page 3 of 4
MICHELLE R COTE RUIZ 121889036

Tax computation, credits, and other taxes

PY
38 Taxable income (from line 37 on page 2) ....................................................................................... 38 22053 .
39 1<6WD[RQOLQHDPRXQW.......................................................................................................... 39 1050.
40 1<6KRXVHKROGFUHGLW ........................................................ 40 .

NO HANDWRITTEN ENTRIES, OTHER THAN SIGNATURE, ON THIS FORM

41 5HVLGHQWFUHGLW .................................................................. 41 .
42 2WKHU1<6QRQUHIXQGDEOHFUHGLWV(Form IT-201-ATT, line 7) ... 42 .

CO
43 $GGOLQHVDQG.............................................................................................................. 43 .
44 6XEWUDFWOLQHIURPOLQH(if line 43 is more than line 39, leave blank) .......................................... 44 1050.
45 1HWRWKHU1<6WD[HV(Form IT-201-ATT, line 30) ............................................................................. 45 .
46 Total New York State taxes (add lines 44 and 45) ........................................................................ 46 1050.
New York City and Yonkers taxes, credits, and surcharges, and MCTMT

47 1<&WD[DEOHLQFRPH ......................................................... 47

EW 22053.
47a 1<&UHVLGHQWWD[RQOLQHDPRXQW ................................ 47a 748. See instructions to
compute New York City and
48 1<&KRXVHKROGFUHGLW ...................................................... 48 . Yonkers taxes, credits, and
49 6XEWUDFWOLQHIURPOLQHD(if line 48 is more than surcharges.
line 47a, leave blank) ........................................................ 49 748.

LE
50 3DUW\HDU1<&UHVLGHQWWD[(Form IT-360.1) ....................... 50 .
51 2WKHU1<&WD[HV(Form IT-201-ATT, line 34) ........................ 51 .
52 $GGOLQHVDQG .................................................. 52 748.
I
53 1<&QRQUHIXQGDEOHFUHGLWV(Form IT-201-ATT, line 10) ........ 53 .
EV

54 6XEWUDFWOLQHIURPOLQH (if line 53 is more than

748.

FI
line 52, leave blank) ......................................................... 54
54a 0&707QHWHDUQLQJV
EDVHIRU=RQH.. 54a .
54b 0&707QHWHDUQLQJV
EDVHIRU=RQH .. 54b .
PR

54c 0&707IRU=RQH .......................................................... 54c .

T
54d 0&707IRU=RQH .......................................................... 54d . See instructions to compute
54e Total MCTMT (add lines 54c and 54d) ................................ 54e . the MCTMT for each zone.
NO

55 <RQNHUVUHVLGHQWLQFRPHWD[VXUFKDUJH .......................... 55 .

56 <RQNHUVQRQUHVLGHQWHDUQLQJVWD[(Form Y-203) ............... 56 .
57 3DUW\HDU<RQNHUVUHVLGHQWLQFRPHWD[VXUFKDUJH(Form IT-360.1) 57 .
58 Total New York City and Yonkers taxes / surcharges and MCTMT (add lines 54 and 54e through 57) .. 58 748.

59 Sales or use tax (do not leave blank) ......................................................................................... 59 0.

60 Voluntary contributions (Form IT-227, Part 2, line 1) ................................................................... 60 .

DO

61 Total New York State, New York City, Yonkers, and sales or use taxes, MCTMT, and
voluntary contributions (add lines 46, 58, 59, and 60) ............................................................. 61 1798.

201003231201
Page 4 of 4 IT-201  <RXU6RFLDO6HFXULW\QXPEHU
121889036
62 (QWHUDPRXQWIURPOLQH ........................................................................................................... 62 1798.
Payments and refundable credits

PY
63 (PSLUH6WDWHFKLOGFUHGLW .................................................. 63 .
64 1<61<&FKLOGDQGGHSHQGHQWFDUHFUHGLW ...................... 64 .
65 1<6HDUQHGLQFRPHFUHGLW (,&  ............................... 65 .
66 1<6QRQFXVWRGLDOSDUHQW(,& .......................................... 66 .

NO HANDWRITTEN ENTRIES, OTHER THAN SIGNATURE, ON THIS FORM

67 5HDOSURSHUW\WD[FUHGLW .................................................... 67 .
68 &ROOHJHWXLWLRQFUHGLW......................................................... 68 .

CO
69 1<&VFKRROWD[FUHGLW ¿[HGDPRXQW (also complete F on page 1) 69 63.
69a 1<&VFKRROWD[FUHGLW UDWHUHGXFWLRQDPRXQW ................. 69a 44.
70 1<&HDUQHGLQFRPHFUHGLW ........................................ 70 .
70a 7KLVOLQHLQWHQWLRQDOO\OHIWEODQN ........................................ 70a
71 2WKHUUHIXQGDEOHFUHGLWV (Form IT-201-ATT, line 18) ............. 71 . ,IDSSOLFDEOHFRPSOHWH Form(s) IT-2
72 Total New York StateWD[ZLWKKHOG ................................... 72 1101. and/or IT-1099-RDQGVXEPLWWKHP
ZLWK\RXUUHWXUQ
73 Total New York CityWD[ZLWKKHOG ..................................... 73 807.
74 Total YonkersWD[ZLWKKHOG...............................................
EW 74 . Do not send federal Form W-2
with your return.
75 7RWDOHVWLPDWHGWD[SD\PHQWVandDPRXQWSDLGZLWK)RUP,7 75 .
76 Total payments (add lines 63 through 75) ..................................................................................... 76 2015.

LE
Your refund, amount you owe, and account information
77 Amount overpaid (if line 76 is more than line 62, subtract line 62 from line 76) ................................ 77 217.
78 $PRXQWRIOLQHavailable for refund (subtract line 79 from line 77) .......................................... 78 217.
I
TIP:8VHWKLVDPRXQWWRFKHFN\RXUUHIXQGVWDWXVRQOLQH
78a $PRXQWRIOLQHWKDW\RXZDQWWRGHSRVLWLQWRD1<6DFFRXQW(Form IT-195, line 4) (also submit Form IT-195) 78a .
EV

78b 7RWDOUHIXQGDIWHU1<6DFFRXQWGHSRVLW(subtract line 78a from line 78) .................................. 78b 217.

FI
X direct depositWRFKHFNLQJRU - or - paper
Refund?'LUHFWGHSRVLWLVWKH
Mark one refund choice: VDYLQJVDFFRXQW ¿OOLQOLQH check
HDVLHVWIDVWHVWZD\WRJHW\RXU
79 $PRXQWRIOLQHWKDW\RXZDQWDSSOLHGWR\RXU UHIXQG
   HVWLPDWHGWD[(see instructions) ....................................... 79 . See instructions for payment
PR

80 $PRXQW\RXowe (if line 76 is less than line 62, subtract line 76 from line 62). 7RSD\E\HOHFWURQLF
T
options.
   IXQGVZLWKGUDZDOPDUNDQXLQWKHER[ DQG ¿OOLQOLQHVDQG,I\RXSD\E\FKHFN
   RUPRQH\RUGHU\RXmustFRPSOHWH)RUP,79DQGPDLOLWZLWK\RXUUHWXUQ .................. 80 .
NO

81 (VWLPDWHGWD[SHQDOW\(include this amount in line 80 or

reduce the overpayment on line 77) .................................... 81 . See instructions for the proper
82 2WKHUSHQDOWLHVDQGLQWHUHVW ............................................. 82 . assembly of your return.
83 $FFRXQWLQIRUPDWLRQIRUGLUHFWGHSRVLWRUHOHFWURQLFIXQGVZLWKGUDZDO.
  ,IWKHIXQGVIRU\RXUSD\PHQW RUUHIXQG ZRXOGFRPHIURP RUJRWR DQDFFRXQWRXWVLGHWKH86PDUNDQXLQWKLVER[ ............
83a $FFRXQWW\SH X 3HUVRQDOFKHFNLQJ - or - 3HUVRQDOVDYLQJV - or - %XVLQHVVFKHFNLQJ - or - %XVLQHVVVDYLQJV

83b 5RXWLQJQXPEHU 096017418 83c $FFRXQWQXPEHU 5117248746624

DO

84 (OHFWURQLFIXQGVZLWKGUDZDO..................................... 'DWH $PRXQW .

Third-party  3ULQWGHVLJQHH¶VQDPH 'HVLJQHH¶VSKRQHQXPEHU 3HUVRQDOLGHQWL¿FDWLRQ

QXPEHU 3,1
designee? (see instr.) ( )
Yes No X  (PDLO

ź Paid preparer must complete ź 3UHSDUHU¶V1<735,1 1<735,1

ź Taxpayer(s) must sign here ź
(see instructions) excl. code
3UHSDUHU¶VVLJQDWXUH 3UHSDUHU¶VSULQWHGQDPH <RXUVLJQDWXUH

)LUP¶VQDPH(or yours, if self-employed)   3UHSDUHU¶V37,1RU661 <RXURFFXSDWLRQ

MAINTENANCE ASSOCIATE
$GGUHVV   (PSOR\HULGHQWL¿FDWLRQQXPEHU 6SRXVH¶VVLJQDWXUHDQGRFFXSDWLRQ(if joint return)

Date 'DWH 'D\WLPHSKRQHQXPEHU

615 2239 ( 347 )
(PDLO (PDLO MR098990@GMAIL.COM
201004231201 See instructions for where to mail your return.
 IT-2
Department of Taxation and Finance

Summary of W-2 Statements

New York State • New York City • Yonkers
Do not detach or separateWKH:5HFRUGVEHORZ)LOH)RUP,7DVDQHQWLUHSDJHZLWK\RXUUHWXUQ6HHLQVWUXFWLRQV

PY
Box c Employer’s information
W-2 Record 1 Employer’s name

Box a Employee’s 6RFLDO6HFXULW\QXPEHU EQUINOX HOLDINGS INC

for this W-2 Record Employer’s address (number and street)

121889036 31 HUDSON YARDS 15 FLOOR

Box b (PSOR\HULGHQWL¿FDWLRQQXPEHU (,1 &LW\ 6WDWH =,3FRGH &RXQWU\

CO
134034296 NEW YORK NY 10001
Box 1 Wages, tips, other compensation Box 12a $PRXQW &RGH Box 14a $PRXQW 'HVFULSWLRQ
30053.00 67.00 DD 137.00 NYPFL
Box 8 Allocated tips Box 12b $PRXQW &RGH Box 14b $PRXQW 'HVFULSWLRQ
.00 .00 31.00 NYSDI
Box 10 'HSHQGHQWFDUHEHQH¿WV Box 12c $PRXQW &RGH Box 14c $PRXQW 'HVFULSWLRQ
.00 .00 .00

NO HANDWRITTEN ENTRIES ON THIS FORM

Box 11 1RQTXDOL¿HGSODQV Box 12d $PRXQW
EW &RGH Box 14d $PRXQW 'HVFULSWLRQ
.00 .00 .00

Box 13 6WDWXWRU\HPSOR\HH Retirement plan 7KLUGSDUW\VLFNSD\ &RUUHFWHG :F

Box 16a 1<6ZDJHVWLSVHWF Box 17a 1<6LQFRPHWD[ZLWKKHOG

LE
NY6WDWHLQIRUPDWLRQ Box 15a
1<6WDWH N Y 30053.00 1101.00
Box 16b 2WKHUVWDWHZDJHVWLSVHWF Box 17b 2WKHUVWDWHLQFRPHWD[ZLWKKHOG
OtherVWDWHLQIRUPDWLRQ Box 15b
other state .00 .00
I
EV

NYC and Yonkers Box 18 /RFDOZDJHVWLSVHWF  Box 19 /RFDOLQFRPHWD[ZLWKKHOG  Box 20 Locality name
information (see instr.)
30054.00 807.00 NYC

FI
Locality a Locality a Locality a

/RFDOLW\E .00 /RFDOLW\E .00 /RFDOLW\E

Do not detach. Box c Employer’s information

W-2 Record 2 Employer’s name
PR

T
Box a Employee’s 6RFLDO6HFXULW\QXPEHU
for this W-2 Record Employer’s address (number and street)
NO
Box b (PSOR\HULGHQWL¿FDWLRQQXPEHU (,1 &LW\ 6WDWH =,3FRGH &RXQWU\

Box 1 Wages, tips, other compensation Box 12a $PRXQW &RGH Box 14a $PRXQW 'HVFULSWLRQ
.00 .00 .00
Box 8 Allocated tips Box 12b $PRXQW &RGH Box 14b $PRXQW 'HVFULSWLRQ
.00 .00 .00
Box 10 'HSHQGHQWFDUHEHQH¿WV Box 12c $PRXQW &RGH Box 14c $PRXQW 'HVFULSWLRQ
.00 .00 .00
DO

Box 11 1RQTXDOL¿HGSODQV Box 12d $PRXQW &RGH Box 14d $PRXQW 'HVFULSWLRQ
.00 .00 .00

Box 13 6WDWXWRU\HPSOR\HH Retirement plan 7KLUGSDUW\VLFNSD\ &RUUHFWHG :F

Box 16a 1<6ZDJHVWLSVHWF Box 17a 1<6LQFRPHWD[ZLWKKHOG
NY6WDWHLQIRUPDWLRQ Box 15a
1<6WDWH N Y .00 .00
Box 16b 2WKHUVWDWHZDJHVWLSVHWF Box 17b 2WKHUVWDWHLQFRPHWD[ZLWKKHOG
OtherVWDWHLQIRUPDWLRQ Box 15b
other state .00 .00

NYC and Yonkers Box 18 /RFDOZDJHVWLSVHWF Box 19 /RFDOLQFRPHWD[ZLWKKHOG Box 20 Locality name
information (see instr.)
Locality a .00 Locality a .00 Locality a

/RFDOLW\E .00 /RFDOLW\E .00 /RFDOLW\E

102001231201