Form 40 - Oregon Individual Income Tax Return - 2011
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2-D with header only
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2-D with grid & data
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Form
For office use only
Amended return
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Amended Return
40
2011
OREGON
2011
OREGON INDIVIDUAL INCOME TAX RETURN
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Full-Year Residents Only
For office use only
Form
40
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Fiscal year ending
6
INDIVIDUAL INCOME TAX RETURN
K
F
P
J
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7
p s s n x x - x x x x
s s s n x x - x x x x
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8
Full-Year Residents Only
p l A s t n A m e x x x x x x x x x x x p f i R s t n A m e x x i
D o b
x x / x x / x x x x
Fiscal year ending
D e c e A s e D
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9
K
F
P
J
W
s l A s t n A m e x x x x x x x x x x x s f i R s t n A m e x x i
D o b
x x / x x / x x x x
D e c e A s e D
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10
e x t e n s i o n f i l e D
A D D R e s s 1 x x x x x x x x x x x x x x x x x x x x x x x x x x x
p h o n e
x x x - x x x - x x x x
Last name
First name and initial
Date of birth
(mm/dd/yyyy)
Social Security No. (SSN)
11
11
A D D R e s s 2 x x x x x x x x x x x x x x x x x x x x x x x x x x x
8 8 8 6
–
–
Deceased
12
12
c i t y x x x x x x x x x x x x x x x x x s t Z i p x x x x x x x
n e W n A m e / A D D R e s s
Spouse’s/RDP’s last name if joint return
Spouse’s/RDP’s first name and initial if joint return
Spouse’s/RDP’s SSN if joint return
c l A i m e D / D e p e n D e n t
Date of birth
(mm/dd/yyyy)
13
13
–
–
c o u n t R y x x x x x x x x x x x x x x x
f o R c o m p u t e R u s e o n l y
Deceased
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f i l i n g s t A t u s :
x x x x x x x x x x x x x x x x x x x x x
Current mailing address
Telephone number
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(
)
s p o u s e :
x x x x x x x x x x x x x x x s s n - x x - x x x x
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16
City
State
ZIP code
Country
p A R t n e R :
x x x x x x x x x x x x x x x s s n - x x - x x x x
If you filed a return last year, and your
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17
q u A l i f y i n g n A m e :
x x x x x x x x x x x x x x x x x x
name or address is different, check here
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•
PRINT 2-D BARCODE HERE
e x e m p t i o n s :
Filing
1
Single
Exemptions
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19
Status
•
•
6 A s e l f :
2a
R e g u l A R
D i s A b l e D
x
Married filing jointly
Total
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20
2b
Registered domestic partners (RDP) filing jointly
Check
6 b s p o u s e / R D p :
R e g u l A R
D i s A b l e D
x
6a
6a
21
Yourself ...........
Regular
...... Severely disabled
....
21
only
3a
Married filing separately:
6 c A l l D e p e n D e n t s :
x x x x x x x x x x x x x x
x x
one
6b
b
22
Spouse/RDP ...
22
Regular
...... Severely disabled
......
Spouse’s name _____________________________ Spouse’s SSN ___________________
⁄
box
1
6 D D i s A b l e D c h i l D R e n o n l y :
x x
Minimum
" white space
•
3b
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Registered domestic partner filing separately:
6c
c
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All dependents
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First names __________________________________
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x
around all four sides of barcode
Partner’s name _____________________________ Partner’s SSN ___________________
•
6d
d
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Disabled
24
First names __________________________________
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Head of household:
Person who qualifies you ________________________________
6 e t o t A l e x e m p t i o n s :
x x
children only
•
Total
6e
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Qualifying widow(er) with dependent child
(see instructions)
7 A s e l f
:
6 5 o R o l D e R
b l i n D
•
•
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26
•
•
•
•
7a
Check
7b
You
7c
You have
7d
Someone
7e
If there is a kicker refund,
s p o u s e / R D p :
6 5 o R o l D e R
b l i n D
all that
You were:
65 or older
Blind
27
filed an
federal
else can claim you
I want to donate mine to the
27
apply
➛
Spouse/RDP was:
State School Fund
65 or older
Blind
extension
Form 8886
as a dependent
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28
Round to the nearest dollar
8 Federal adjusted gross income. Federal Form 1040, line 37; 1040A, line 21; 1040EZ, line 4;
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•
.00
1040NR, line 36; or 1040NR-EZ, line 10. See instructions, page 13 ...........................................................
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•
.00
9 Interest and dividends on state and local government bonds outside of Oregon ...
9
ADDITIONS
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•
•
.00
10y $
10 Other additions. Identify:
10x
10z
10
Schedule included
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•
.00
11 Total additions. Add lines 9 and 10 .............................................................................................................
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•
.00
12 Income after additions. Add lines 8 and 11 .................................................................................................
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•
.00
13 2011 federal tax liability ($0–$5,950; see instructions for the correct amount) .....
13
SUBTRACTIONS
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•
.00
Include
14 Social Security included on federal Form 1040, line 20b; or Form 1040A, line 14b ...
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proof of
•
.00
15 Oregon income tax refund included in federal income ............................................
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withholding
•
.00
16 Interest from U.S. government, such as Series EE, HH, and I bonds .....................
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(W-2s,
•
.00
% ...
% 17b
1099s),
17 Federal pension income. See instructions, page 15. 17a
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payment,
•
•
•
.00
18y $
18 Other subtractions. Identify:
18x
18z
18
Schedule included
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and payment
•
.00
19 Total subtractions. Add lines 13 through 18 ................................................................................................
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voucher
•
.00
20 Income after subtractions. Line 12 minus line 19 ........................................................................................
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If you are claiming itemized deductions, fill in lines 21–25. If you are claiming the standard deduction, fill in line 26 only.
DEDUCTIONS
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.00
21 Itemized deductions from federal Schedule A, line 29 ............................................
21
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.00
22 Special Oregon medical deduction (age restricted, see instructions, page 17) ......
22
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.00
23 Total Oregon itemized deductions. Add lines 21 and 22 .........................................
23
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.00
24 State income tax claimed as an itemized deduction ..........................................
24
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•
.00
25 Net Oregon itemized deductions. Line 23 minus line 24.........................................
25
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Either line 25 or 26
OR
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.00
26 Standard deduction from page 17 ...........................................................................
26
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.00
27 Total deductions. Line 25 or line 26, whichever is larger .........................................................................
27
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.00
28 Oregon taxable income. Line 20 minus line 27. If line 27 is more than line 20, enter -0- .........................
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•
.00
29 Tax. See instructions, page 18. Enter tax here ........................................................
29
TAX
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•
•
Check if tax is from: 29a
Tax tables or charts or
29b
Form FIA-40 or
29c
Worksheet FCG
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.00
30 Interest on certain installment sales .........................................................................
30
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.00
31 Total tax before credits. Add lines 29 and 30 ...................................
OREGON TAX BEFORE CREDITS
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➛
NOW GO TO THE BACK OF THE FORM
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150-101-040-2 (Rev. 12-11)
150-101-040 (Rev. 12-11)
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