Form 40 - Oregon Individual Income Tax Return - 2011 Page 2

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Page 2 — 2011 Form 40
—Remember to reprint page 1 if any changes are made on this page.
70
70
.00
32 Total tax before credits from front of form, line 31 .......................................................................................... 32
71
71
33 Exemption credit. If the amount on line 8 is less than $127,150, multiply your
NONREFUNDABLE
72
72
CREDITS
•
.00
total exemptions on line 6e by $179. Otherwise, see instructions on page 18 .......
33
73
73
•
.00
34 Retirement income credit. See instructions, page 19 ..............................................
34
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.00
•
35 Child and dependent care credit. See instructions, page 20 ...................................
35
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75
•
.00
ADD TOGETHER
36 Credit for the elderly or the disabled. See instructions, page 20 .............................
36
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76
•
.00
37 Political contribution credit. See limits, page 23 ......................................................
37
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.00
•
•
Include proof
38 Credit for income taxes paid to another state. State:
38y
38z ...
38
Schedule included
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78
•
•
•
.00
39y $
39 Other credits. Identify:
39x
39z
39
Schedule included
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•
.00
40 Total non-refundable credits. Add lines 33 through 39 ................................................................................
40
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80
•
.00
41 Net income tax. Line 32 minus line 40. If line 40 is more than line 32, enter -0- .........................................
41
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81
•
.00
42 Oregon income tax withheld. Include Form(s) W-2 and 1099 ..............................
42
PAYMENTS AND
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REFUNDABLE
•
.00
43 Estimated tax payments for 2011 and payments made with your extension .............
43
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83
CREDITS
•
.00
44 Earned income credit. See instructions, page 25 ....................................................
44
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84
Include Schedule
ADD TOGETHER
•
.00
Working family child care credit
45
from WFC, line 18 ..............................................
45
WFC if you claim
85
85
this credit
.00
•
46 Mobile home park closure credit. Include Schedule MPC .......................................
46
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86
•
.00
47 Total payments and refundable credits. Add lines 42 through 46 ................................................................
47
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•
.00
➛
48
Overpayment.
If line 41 is less than line 47, you overpaid. Line 47 minus line 41 ....
OVERPAYMENT
48
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88
•
.00
➛
TAX TO PAY
49
49
Tax to pay.
If line 41 is more than line 47, you have tax to pay. Line 41 minus line 47 ....
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.00
50 Penalty and interest for filing or paying late. See instructions, page 25 ..................... 50
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90
•
.00
51 Interest on underpayment of estimated tax. Include Form 10 and check box
51
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91
•
•
Exception # from Form 10, line 1
51a
Check box if you annualized
51b
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.00
52 Total penalty and interest due. Add lines 50 and 51 ....................................................................................... 52
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93
➛
•
.00
53
Amount you owe.
Line 49 plus line 52 ...............................................................
AMOUNT YOU OWE
53
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94
➛
•
.00
REFUND
54
Refund.
Is line 48 more than line 52? If so, line 48 minus line 52 ..........................................
54
95
95
•
.00
Estimated tax.
Fill in the part of line 54 you want applied to 2012 estimated tax ...
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55
96
96
.00
.00
•
•
CHARITABLE
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57
Oregon Nongame Wildlife
Prevent Child Abuse
97
97
CHECkOFF
.00
.00
•
•
58
59
Alzheimer’s Disease Research
Stop Dom. & Sexual Violence
98
98
DONATIONS,
.00
.00
•
•
60
61
AIDS/HIV Education & Svcs.
Habitat for Humanity
99
These will
99
PAGE 14
.00
.00
•
•
reduce
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OR Head Start Association
OR Military Financial Assist.
100
100
I want to donate
your refund
.00
.00
•
•
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65
Oregon Historical Society
Oregon Food Bank
101
101
part of my tax
.00
.00
•
•
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67
refund to the
Albertina Kerr Centers
American Red Cross
102
102
.00
.00
•
•
•
•
following fund(s)
68a
68b
69a
69b
Charity code
Charity code
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103
.00
•
•
•
70
70a
70b
........
70
104
104
Political party $3 checkoff. Party code:
You
Spouse/RDP
See instructions
.00
•
71 Total. Add lines 55 through 70. Total can’t be more than your refund on line 54 .........................................
71
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➛
.00
•
72
NET REFUND.
Line 54 minus line 71. This is your net refund .....................................
NET REFUND
72
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107
•
73 For direct deposit of your refund, see instructions, page 26.
Type of account:
Checking or
Savings
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108
DIRECT
•
•
DEPOSIT
Routing No.
Account No.
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109
•
Will this refund go to an account outside the United States?
Yes
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111
Important: Include a copy of your federal Form 1040, 1040A, 1040EZ, 1040NR, or 1040NR-EZ.
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Under penalty for false swearing, I declare that the information in this return is true, correct, and complete.
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•
License No.
Your signature
Date
Signature of preparer other than taxpayer
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115
X
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116
X
Address
Telephone No.
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117
Spouse’s/RDP’s signature (if filing jointly, BOTH must sign)
Date
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118
X
119
119
If you owe, make your check or money order payable to the
Oregon Department of Revenue.
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Write your daytime telephone number and “2011 Oregon Form 40” on your check or money order.
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Include your payment, along with the payment voucher
on page 19, with this return.
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MAIL RETURNS (NON-2-D BARCODE) TO:
MAIL 2-D BARCODE RETURNS TO:
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Mail
Oregon Department of Revenue
REFUND
Mail
returns
REFUND
Tax-to-Pay:
Refunds and No Tax Due:
Tax-to-Pay:
Refunds and No Tax Due:
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TAX-TO-PAY
PO Box 14555
and
NO-TAX-DUE
PO Box 14700
Oregon Department of Revenue
Oregon Department of Revenue
Oregon Department of Revenue
Oregon Department of Revenue
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returns to
Salem OR 97309-0940
returns to
Salem OR 97309-0930
PO Box 14555
PO Box 14700
PO Box 14720
PO Box 14710
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126
Salem OR 97309-0940
Salem OR 97309-0930
Salem OR 97309-0463
Salem OR 97309-0460
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150-101-040-2 (Rev. 12-11)
150-101-040 (Rev. 12-11)
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