Form 40s - Individual Income Tax Return - 2004
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1
2Clear Form
W
Form
OREGON
For office use only
2004
40S
Individual Income Tax Return
1
2
3
SHORT FORM
FULL-YEAR RESIDENTS ONLY
Last name
First name and initial
Date of birth (mm/dd/yyyy)
Social Security No. (SSN)
–
–
Date of birth (mm/dd/yyyy)
Spouse’s last name if joint return
Spouse’s first name and initial if joint return
Spouse’s SSN, if joint return
–
–
Current mailing address
Telephone number
(
)
City
State
ZIP code
Country
If you filed a return last year, and your
name or address is different, check here
•
•
Exemptions
Total
Filing
1
Single
Status
2
6a Yourself......
6a
Married filing jointly
Regular
........ Severely disabled
.........
Check
3
6b Spouse ......
b
Married filing
Regular
........ Severely disabled
...........
Spouse’s name
only
separately
one
•
6c All de pen dents
c
Spouse’s SSN
First names ________________________________
box
4
•
Head of household
6d Child(ren)
d
Person who qualifies you
First names ________________________________
with a disability
•
5
Qualifying widow(er) with dependent child
6e
Total
•
•
7a
•
Check
7c
You attached
7b
You
7d
Someone else
7e
If there is a kicker refund,
You were:
65 or older
Blind
all that
Schedule
filed an
can claim you as
you want to donate your
➛
apply
Spouse was:
65 or older
Blind
kicker to the State School Fund
extension
a dependent
WFC
+
+
Round to the nearest dollar
8 Wages
)
unemployment
interest and dividends
(enter in box 8a
(enter in box 8b)
(enter in box 8c)
➛
.00
•
+
•
+
•
=
•
TOTAL INCOME
8a
.00
8b
.00
8c
.00
8
•
.00
9 2004 federal tax liability ($0–$4,000; see instructions for the correct amount) ...........
9
.00
•
10 Standard deduction from the back of this form ...........................................................
10
.00
11 Add lines 9 and 10...............................................................................................................................................
11
.00
•
12 Oregon taxable income.
...........................................
Line 8 minus line 11. If line 11 is more than line 8, fill in -0-
12
•
.00
13 Tax. See pages 21 through 23 for tax tables or charts and enter tax here ....................................................
13
.00
•
14
Exemption credit.
Multiply your total exemptions on line 6e by $151 .......................
14
Staple
.00
•
15 Earned income credit. See instructions, page 10........................................................
15
W-2s,
.00
•
16 Child and dependent care credit. See instructions, page 10.......................................
payment,
16
and
.00
•
17 Other credits (see instructions). Identify __________________________________
17
payment
.00
18 Total credits. Add lines 14 through 17 .................................................................................................................
18
voucher
•
.00
19 Net income tax. Line 13 minus line 18. If line 18 is more than line 13, fill in -0- ..............................................
19
here
.00
•
20 Oregon income tax withheld. Attach your Form(s) W-2 and 1099 ...........................
20
Attach Schedule
➛
.00
•
21
Working family child care credit
from WFC, line
19.............CREDIT AMOUNT
21
WFC if you claim
.00
•
•
Number from WFC, line 5
Amount from WFC, line 17
21a
21b
this credit
.00
22 Total payments. Add lines 20 and 21 ..................................................................................................................
22
➛
.00
•
23
Re fund.
If line 22 is more than line 19, you have a refund. Line 22 minus line 19 ...................
RE FUND
23
➛
•
.00
.............TAX TO PAY
24
Tax to pay.
If line 19 is more than line 22 , you have tax to pay. Line 19 minus line 22
24
.00
•
CHARITABLE
25 Oregon Nongame Wildlife ...............
$1 ......
$5 .....
$10 .....
25
Other $______
CHECKOFFS
.00
•
26 Child Abuse Prevention...................
$1 ......
$5 .....
$10 .....
26
Other $______
I want to
These will
.00
•
donate part
27 Alzheimer’s Disease Research .......
$1 ......
$5 .....
$10 .....
27
Other $______
reduce
of my tax
.00
•
28 Stop Domestic & Sexual Violence...
$1 ......
$5 .....
$10 .....
28
Other $______
your refund
refund to
.00
the following
•
29 AIDS/HIV Education and Services ...
$1 ......
$5 .....
$10 .....
29
Other $______
fund(s)
•
.00
•
30 Other charity. Enter code
____ ....
$1 ......
$5 .....
$10 .....
30
Other $______
.00
31 Total. Add lines 25 through 30. Total can’t be more than your refund on line 23.................................................
31
➛
.00
32
NET REFUND.
Line 23 minus line 31. This is your net refund.............................................
NET REFUND
32
33 For direct deposit of your refund, see the instructions on page 12.
DIRECT
•
Type of Account:
Checking or
Savings
DE POS IT
•
•
Routing No.
Account No.
Under penalties for false swearing, I declare that I have examined this return, including accompanying sched ules and
I authorize the Department of
state ments. To the best of my knowledge and belief it is true, correct, and complete. If prepared by a person other than the
Revenue to contact this preparer
taxpayer, this declaration is based on all information of which the preparer has any knowledge.
about the processing of this return.
Your signature
Date
Signature of preparer other than taxpayer
License No.
X
X
SIGN
HERE
Address
Telephone No.
Spouse’s signature
(if filing jointly, BOTH must sign)
Date
X
150-101-044 (Rev. 12-04) Web
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