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3 Preparer s PTIN P. 4 FEIN P. 5 Preparer s phone number P. 2 NM P. 6 See PIT-1 instructions. Date Amount 1a Sum of payments 2a Sum of refunds 3. You must complete both lines 16 and 16a or the deduction will be denied. 16a. Unreimbursed and uncompensated medical care expenses. 2012 PIT-X PAGE 1 BARCODE SHOULD READ 120169999 where the last four digits are replaced with your vendor code. Enter 1 2 3 4 or 5 in the box if you owe penalty on underpayment of estimated tax and you qualify. Attach...
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