Form N-11 - Individual Income Tax Return (Resident)

Form N-11 (Rev. 2016)

Page 4 of 4

Your Social Security Number

Your Spouse’s SSN

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JBB164

Name(s) as shown on return ___________________________________________________

Amount of line 45 to be applied to your

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2017 ESTIMATED TAX ..................................................... 46

47a

Amount to be REFUNDED TO YOU (line 45 minus line 46) If filing late,

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see page 29 of Instructions ........................................................................................................... 47a

Fill in this oval if this refund will ultimately be deposited to a foreign (non-U.S.) bank. Do not complete lines 47b, 47c, or 47d.

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47b

Routing number

47c Type:

Checking

Savings

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47d

Account number

AMOUNT YOU OWE (line 36 minus line 41). Send Form N-200V with your payment.

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Make check or money order payable to the “Hawaii State Tax Collector”. ..................................... 48

Estimated tax penalty. (See page 30 of

Instructions.) Do not include on line 42 or 48. Fill in

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................... 49

this oval if Form N-210 is attached

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AMENDED RETURN ONLY – Amount paid (overpaid) on original return. (See Instructions) (attach Sch. AMD) ....... 50

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AMENDED RETURN ONLY – Balance due (refund) with amended return. (See Instructions) (attach Sch. AMD) ..... 51

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52 Did you file a federal Schedule C?

If yes, enter Hawaii gross receipts

Yes

your main business activity:

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your main business product:

AND your HI Tax I.D. No. for this activity

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53 Did you file a federal Schedule E

If yes, enter Hawaii gross rents received

for any rental activity?

Yes

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AND your HI Tax I.D. No. for this activity

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54 Did you file a federal Schedule F?

Yes

If yes, enter Hawaii gross receipts

your main business activity:

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AND your HI Tax I.D. No. for this activity

your main business product:

If designating another person to discuss this return with the Hawaii Department of Taxation, complete the following. This is not a full power of

attorney. See page 31 of the Instructions.

Designee’s name

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Phone no.

†

Identification number

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HAWAII ELECTION

Note: Filling in the “Yes”

Do you want $3 to go to the Hawaii Election Campaign Fund?

Yes

CAMPAIGN FUND

oval will not increase your

If joint return, does your spouse want $3 to go to the fund?

Yes

tax or reduce your refund.

(See page 31 of the Instructions)

DECLARATION — I declare, under the penalties set forth in section 231-36, HRS, that this return (including accompanying schedules or statements) has been examined by me and, to the best

of my knowledge and belief, is a true, correct, and complete return, made in good faith, for the taxable year stated, pursuant to the Hawaii Income Tax Law, Chapter 235, HRS.

Your signature

Date

Spouse’s signature (if filing jointly, BOTH must sign)

Date

†

Your Occupation

Daytime Phone Number

Your Spouse’s Occupation

Daytime Phone Number

Date

Preparer’s identification number

Preparer’s